emDocs.net Podcast – Episode 8: SJS/TEN Mimics, Rapid Hand Exam, Penile Injuries

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover three posts: SJS/TEN Mimics, Rapid Hand Neuro Exam, and Penile Zipper Injuries and Entrapment

Part 1: SJS/TEN Mimics

Key Points from the Podcast and Post:

1. SJS and TEN are life-threatening skin conditions that may begin with systemic symptoms. SJS involves < 10% TBSA, while TEN is > 30% TBSA.
2. Risk factors for developing SJS/TEN include patients with active cancer, HIV, women, and several medications. The common medication offenders include NSAIDs, trimethoprim-sulfamethoxazole, phenobarbital, carbamazepine, lamotrigine, acetaminophen, and chemotherapeutic agents.
3. Mimics of SJS/TEN include Acute Generalized Exanthematous Pustulosis (AGEP), Erythema multiforme (EM), Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), Pemphigus Vulgaris (PV), meningococcemia, Staphylococcal Scalded Skin Syndrome (SSSS), and Erythroderma.
4. When approaching these patients, take a thorough history. Identifying any new medication exposures over the past several months is valuable information.
5. The Nikolsky sign (skin sloughing with lateral pressure) and presence of mucosal involvement can be important differentiating factors in identifying critical rashes.  SJS/TEN, pemphigus vulgarisms, and SSSS are Nikolsky positive.
6. Treatment Breakdown:

• • SJS/TEN: supportive care, treat like any other burn
  • AGEP: supportive care, +/- topical steroids
  • EM: supportive care, consider IV or PO steroids if major
  • DRESS: topical steroids, systemic steroids if solid organ involvement
  • Pemphigus vulgaris: systemic glucocorticoids + nonsteroidal systemic immunomodulatory medications
  • Meningococcemia: antibiotics
  • SSSS: antibiotics
  • Erythroderma: supportive care, topical steroids

Part 2: Rapid Hand Neuro Exam

Key Points from the Podcast and Post:

Part 3: Penile Zipper Injuries and Entrapment

Key Points from the Podcast and Post:

1: Penile zipper injury

• Determine if the penis is stuck in the sliding mechanism of the zipper or between the teeth.
• Give appropriate analgesia. Great options if patient is without an IV include topical as well as intranasal agents. Penile dorsal nerve block is also a very effective tool.
• If the penis is caught between the teeth, cut across the entire zipper either above or below (preferred and usually easier) the tissue. The zipper teeth should then come apart easily and free the tissue.
• If the penis is caught within the sliding mechanism, multiple modalities should be attempted. This type of zipper injury is much more difficult to relieve and analgesia should thoroughly be addressed. Depending on the patient agitation, they may even require procedural sedation to allow for effective liberation techniques.
• First start with mineral oil or soap and water and try to pull the tissue from the sliding mechanism gently. If this is not successful, attempt to cut the median bar of the zipper with bone or bolt cutters. If you can cut completely through the median bar, the anterior and posterior faceplates will no longer be connected and the zipper can easily be pulled apart. You can also attempt to wedge a screwdriver between the anterior and posterior faceplates and rotate 90 degrees. This should either open up the space between the faceplates enough to pull out the trapped skin or completely disengage the sliding mechanism from the zipper teeth.
• If unable to have success with any method of penile liberation, patient will require urology consultation for possible surgical intervention and/or circumcision.

2: Penile strangulation

• Examine the patient and assess for signs of ischemia. Realize that they may have waited a long time to come in due to fear of embarrassment and may not be forthcoming with duration of injury. If any signs of ischemia are suspected, consult with urology immediately prior to attempts to remove in the ED.
• Multiple methods may be used to remove the penis ring. Attempt lubrication and gentle traction first.
• If unsuccessful, consider the string method presented in the video above.
• If attempts are still unsuccessful, patient will need intervention with heavier tools, start first by utilizing your department’s ring cutter. Remember to give appropriate analgesia and at this point, procedural sedation should also be considered due to the anxiety of the situation. Pour ice water during any attempts to cut the ring off to prevent iatrogenic burns.
• If strong enough machines are not available in the ED, the patient may need to go to the OR for use of surgical grade saws and grinders. Also consider calling local fire department to source removal tools.
• Consider antibiotics, particularly if patient is febrile, has signs of ischemia, or appears septic. Also update tetanus if necessary.

Key Points:

• Penile zipper injuries usually occur in pediatric populations. Identify the type of injury to better help guide which techniques to use to free the penile tissue.
• If the skin is caught between the teeth then cut the zipper above or below and pull apart.
• If it is stuck in the sliding mechanism, you must either release the median bar or use a screwdriver to break the sliding mechanism.
• Be certain to address anxiolysis and pain control adequately.
• Penile strangulation occurs more commonly in adult males and usually linked to rings applied around the penis for pleasure which are now difficult to remove.
• Address removal in a stepwise manner and escalate up through more invasive techniques as mentioned above.
• If unable to remove in the ED, consult with urology and/or fire department for stronger tools to cut through the denser metal rings.
• If there are any signs of organ ischemia, urology should be consulted upon identifying these findings.