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 5thmost 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
Management/Disposition of Adult Hyperglycemia
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.
