emDOCs Podcast – Episode 53: Skin Cancer and New Onset Hyperglycemia

Today on the emDOCs cast with Brit Long, MD (@long_brit), we look at two posts: recognizing skin cancer and new onset hyperglycemia.

Episode 53: Skin Cancer in the ED and Management/Disposition of Adult Hyperglycemia

Skin Cancer in the ED 

Melanoma:

• Most concerning skin cancer and the 5^thmost common cancer in the United States
• Enlarging, irregular borders and pigmentation.
• All ages and skin tones affected
• ABCDE rule, “ugly duckling” nevi, subungual and amelanotic lesions in children
• Early recognition and biopsy for diagnosis; excision for definitive therapy

Basal cell carcinoma:

• Most common skin cancer
• Raised, telangiectasias, ulcerations
• Sun and UV exposed areas of the body
• Diagnosis with biopsy; treatment is complete excision, or cryotherapy, photodynamic therapy, radiotherapy, imiquimod cream, and fluorouracil cream

Squamous cell carcinoma:

• Scaly/crusted lesion, may ulcerate
• Sun exposed areas in fair-skinned patients, non-sun exposed areas in darker-skinned patients
• Actinic keratosis (scaly plaque) is precursor lesion
• Diagnosis with biopsy; treatment is excision, cryotherapy, radiotherapy, or immune-modulators

Merkel cell carcinoma:

• Rare and highly aggressive skin cancer
• AEIOU criteria
• Appears similar to basal cell carcinoma but faster growth
• Affects older, fair-skinned patients, immunosuppressed
• Treatment includes excision with or without radiotherapy

A new diagnosis of diabetes can be made in the ED using the ADA criteria:

• Random plasma glucose >200 mg/dL (11.1 mmol/L) AND classic symptoms of hyperglycemia or hyperglycemic crisis OR two of the following abnormal test results: 1) Fasting plasma glucose >126 mg/dL (7.0 mmol/L) 2) A 2-hour plasma glucose >200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test, 3) A1C >5%.
• Type 1 (autoimmune) diabetes can present in adults.
• Consider type 1 diabetes in adult patients with hyperglycemia and severe weight loss, polyuria, or polydipsia. These patients should have ED endocrinology consult or hospital admission.
• For hyperglycemic, stable patients without concern for type 1 diabetes:
  • If asymptomatic with random BG >126 mg/dL (7.0 mmol/L), outpatient follow-up for diabetes screening is appropriate.
  • If symptomatic with a BG between 200 mg/dL (11.1 mmol/L) and 300 mg/dL (16.7 mmol/L), Metformin 500 mg once a day can be safely started in the ED and is usually well tolerated.
  • For severe hyperglycemia (BG >300 mg/dL or 16.7 mmol/L), the patient will likely require long-term insulin therapy. Disposition of these patients will vary by practice environment. Consider initiation of long-acting glargine at 0.1-0.2 units/kg/day on discharge for reliable patients in well-resourced settings with established hospital support.