Burn Unit Management of Toxic Epidermal Necrolysis Robert H.
Demling, MD; Suellyn Ellerbe, RN;
Nicholas J.
Lowe, MB, MRCP
\s=b\ Toxic epidermal necrolysis is the name given to a group of dermatologic disorders characterized by a separation of epidermis and dermis with a subsequent skin slough. The denuded areas have the appearance of a second-degree burn. The complications of infection, negative nitrogen balance, severe pain, and emotional instability are identical to those seen in the patient with major burns. There are difficulties in patient management and advantages in burn unit care. As with the major burn, care of the patient with skin loss from toxic epidermal necrolysis is extremely complex, requiring the expertise of a burn team along with that of the dermatologist. (Arch Surg 113:758-759, 1978)
Toxic epidermal necrolysis (TEN)
tissue edema. Large areas of desquamation were seen on the back, chest, buttocks, and legs, involving approximately 30% of body surface. These areas had the appearance of a second-degree burn that was covered with a purulent exúdate (Figure). The "burns" and some clinically normal skin areas were extremely painful. Pertinent laboratory values included the following: hematocrit, 30%; WBC, 4,100; serum albumin, 2.1 g/dl. She was immediately resuscitated with albumin, fluids, and later, whole blood, after which the orthostatic changes disappeared. The burns were then actively debrided with the patient under ketamine anesthesia, and pigskin was applied to the denuded areas. Immediately after this,
a dermatologie slough that is due to a generalized epidermal separation.' This produces major management problems for physicians and nurses. Complications may develop in patients that may be very unfamiliar to those in attendance. Although the primary disease state is best managed by the dermatologist, patient care is best handled by a burn service. A case of druginduced TEN is presented and discussed.
disease that
causes a
is
massive skin
REPORT OF A CASE A 24-year-old woman was well until a urinary tract infection developed, for which she was given sulfamethoxazole. Approxi¬ mately ten days after treatment was begun, a generalized tender skin rash developed that progressed to widespread desquamation. The oral mucosa and cornea were also involved. The patient was considered to have TEN. She was hospitalized and steroid therapy for systemic effect was started. Large areas of epidermis continued to slough. The denuded areas became colonized with Staphylococcus aureus. A staphylococcal septicemia developed, for which she was treated with appropriate antibiotics. The patient
unable to eat because of oral mucosal involvement and severe and was maintained only on intravenous fluids. The open areas could not be adequately managed because of her extreme discomfort and near psychotic behavior. Twelve days after she was hospitalized, she was transferred to the University Burn Unit, Madison, Wis. On admission, the patient was noted to be frail, extremely anxious, and virtually paralyzed with pain. She had substantial orthostatic hypotension and generalized soft was
generalized pain,
Accepted
for publication Nov 9, 1977. From the Burn Unit and the Departments of Surgery (Dr Demling and Ms Ellerbe) and Dermatology (Dr Lowe), University of Wisconsin Center for Health Sciences, Madison. Ms Ellerbe is now with Harborview Medical Center, Seattle. Reprint requests to Department of Surgery, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706 (Dr Demling).
show typical appearance of sloughing or Whitish gray exúdate is seen overlying that look like second-degree burns.
Left chest and
arm
epidermal necrolysis. these
areas
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/31/2015
the patient was relieved of much pain. With the patient under ketamine anesthesia, wound debridement and pigskin application was performed for the next four days. After this period, because of improved patient cooperation and less pain, narcotics were adequate for wound care. A feeding tube was placed on the day of admission and a high-protein, high-caloric solution was infused by continuous drip to equal her calculated daily caloric requirement of 3,400 and protein requirement of 200 g. Vitamin C, zinc, and therapeutic multiple vitamins were also added. High-dose vitamin A was not given because of its effect on steroid activity. A skin biopsy specimen taken to determine the level of epidermal sepa¬ ration showed necrosis of the upper four to five epidermal cell layers, with cleavage occurring mainly at the suprabasal epidermal layer. These changes were those of drug-induced TEN. Results of direct immunofluorescence skin studies with antihuman IgG, IgM, IgA, and complement C3 on frozen sections were
negative. The patient's
condition rapidly improved and she was able to walk without assistance after one week. Two weeks after admis¬ sion, the wounds were healed, her serum albumin level returned to 3.9 g/dl, and she was able to maintain proper nutrition without supplemental tube feeding. She continued to have some visual difficulties because of damage to the cornea. Hydrocortisone was gradually discontinued with no evidence of new disease.
COMMENT
The prognosis of TEN depends on the etiologic factors. Most children with staphylococcal-induced TEN will recover. Drug-induced TEN, with its deeper plane of epidermal cleavage, has a mortality reported at 20%,2 the major cause of death being infection. Differentiation between the two disorders is best made by history and skin biopsy specimen. Toxic epidermal necrolysis has been associated with other disease states such as irradiation," graft vs host reactions,' and fumigants.4 Sometimes no apparent cause can be determined. The characteristic skin tenderness is classic, and the condition has been previously called the "scalded skin syndrome." Drug-induced TEN is often treated with large doses of corticosteroids for systemic effect, but Lyell- said that there is disagreement about the absolute need for this treatment. Corticosteroids for systemic effect probably should not be used to treat staphylococcal-induced TEN when appropriate antibiotics are the preferred treatment. Generally, patients suffering from this group of disease states have been managed solely by a dermatologie or general medical service with general nursing care. However, as seen in this patient, the problems of infection, providing proper nutrition, pain, and emotional instability that are due to the loss of epidermis are identical to those seen in a patient with major burns. Because these types of '
problems are managed effectively and routinely by a burn service, these patients should be treated in a burn unit. It is there that infection is controlled by vigorous wound care. This includes active debridement and the use of topical antibiotics or biologic dressings to control surface coloniza¬ tion. To accomplish burn debridement, large doses of narcotics are necessary. We have found 4 mg/kg of intra¬ muscular ketamine hydrochloride to be very safe and effective in controlling pain. The magnitude of the nutritional support necessary to control the negative nitrogen balance in the burn victim has only recently been appreciated." Several formulas are
available to estimate caloric needs; we use the Curreri formula.7 The minimum caloric intake is calculated by the sum of 25 x weight in kilograms and 40 x percent body surface burn. Protein needs are two to four times the body weight (kg), depending on existing depletion. Children require more calories and protein than calculated by these formulas because of continued growth needs." It has been well demonstrated that intensive nutritional support greatly decreases morbidity and mortality of persons with burns. A second-degree burn that these dermatologie disorders may produce is extremely painful, particularly if left exposed to air as in the patient described here. Simply covering the area with a topical antibiotic cream will decrease the discomfort. However, large amounts of nar¬ cotics will still be necessary. A major advance has been the use of biologic dressings." This includes homograft or cadaver skin, heterograft or currently, pigskin and most recently, amnotic membrane. When the open areas are covered, there are not only dramatic decreases in pain, but also in caloric and evaporative losses. These tissues also have important antibacterial properties," the exact mecha¬ nism of which is still undetermined. Because of the chronic nature of convalescence from burns or major skin loss, tremendous emotional support is necessary. Patients can tolerate a considerable amount of pain if they understand its cause and the time course of recovery. This is well recognized by members of a burn service. A psychiatrist is usually assigned to a burn unit to help with this support. Once cooperation is lost because of excessive pain and fear as in the patient described here, recovery is greatly prolonged. With current burn care technique, not only survival, but patient comfort can be substantially improved. We there¬ fore believe that the combination of the knowledge of the dermatologist with the expertise of the burn service is necessary to obtain optimal results with TEN.
References 1. Amon RB, Dimon L: Toxic epidermal necrolysis. Arch Dermatol 111:1433-1437, 1975. 2.
Lyell A: A review of toxic epidermal necrolysis. Br J Dermatol 79:662\x=req-\
671, 1967.
3. Peck GC, Herzig GL, Elias PM: Toxic epidermal necrolysis in a patient with graft versus host reaction. Arch Dermatol 105:561-569, 1972. 4. Radimer GF, Davis JF, Ackerman AB: Fumigant-induced toxic epidermal necrolysis. Arch Dermatol 110:103-104, 1974. 5. Moncrief JA: Burns. New Engl J Med 288:444-454, 1973. 6. Davies JWL, Liliedahl SO: Metabolic consequences of an extensive
burn, in Polk HC, Stone HH (eds): Contemporary Burn Management, Boston, Little Brown & Co, 1971, pp 151-170. 7. Curreri PW, Richmond D, Marvin J, et al: Dietary requirements of patients with major burns. J Am Diet Assoc 65:415-417, 1974. 8. Holli BB, Oakes JB: Feeding the burned child. J Am Diet Assoc 67:240\x=req-\ 242, 1975. 9. Artz CP, Rittenbury MS, Yarbrough DR: An appraisal of allografts and xenografts as biological dressings for wounds and burns. Ann Surg 175:934-938, 1972.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/31/2015
Demling, MD; Suellyn Ellerbe, RN;
Nicholas J.
Lowe, MB, MRCP
\s=b\ Toxic epidermal necrolysis is the name given to a group of dermatologic disorders characterized by a separation of epidermis and dermis with a subsequent skin slough. The denuded areas have the appearance of a second-degree burn. The complications of infection, negative nitrogen balance, severe pain, and emotional instability are identical to those seen in the patient with major burns. There are difficulties in patient management and advantages in burn unit care. As with the major burn, care of the patient with skin loss from toxic epidermal necrolysis is extremely complex, requiring the expertise of a burn team along with that of the dermatologist. (Arch Surg 113:758-759, 1978)
Toxic epidermal necrolysis (TEN)
tissue edema. Large areas of desquamation were seen on the back, chest, buttocks, and legs, involving approximately 30% of body surface. These areas had the appearance of a second-degree burn that was covered with a purulent exúdate (Figure). The "burns" and some clinically normal skin areas were extremely painful. Pertinent laboratory values included the following: hematocrit, 30%; WBC, 4,100; serum albumin, 2.1 g/dl. She was immediately resuscitated with albumin, fluids, and later, whole blood, after which the orthostatic changes disappeared. The burns were then actively debrided with the patient under ketamine anesthesia, and pigskin was applied to the denuded areas. Immediately after this,
a dermatologie slough that is due to a generalized epidermal separation.' This produces major management problems for physicians and nurses. Complications may develop in patients that may be very unfamiliar to those in attendance. Although the primary disease state is best managed by the dermatologist, patient care is best handled by a burn service. A case of druginduced TEN is presented and discussed.
disease that
causes a
is
massive skin
REPORT OF A CASE A 24-year-old woman was well until a urinary tract infection developed, for which she was given sulfamethoxazole. Approxi¬ mately ten days after treatment was begun, a generalized tender skin rash developed that progressed to widespread desquamation. The oral mucosa and cornea were also involved. The patient was considered to have TEN. She was hospitalized and steroid therapy for systemic effect was started. Large areas of epidermis continued to slough. The denuded areas became colonized with Staphylococcus aureus. A staphylococcal septicemia developed, for which she was treated with appropriate antibiotics. The patient
unable to eat because of oral mucosal involvement and severe and was maintained only on intravenous fluids. The open areas could not be adequately managed because of her extreme discomfort and near psychotic behavior. Twelve days after she was hospitalized, she was transferred to the University Burn Unit, Madison, Wis. On admission, the patient was noted to be frail, extremely anxious, and virtually paralyzed with pain. She had substantial orthostatic hypotension and generalized soft was
generalized pain,
Accepted
for publication Nov 9, 1977. From the Burn Unit and the Departments of Surgery (Dr Demling and Ms Ellerbe) and Dermatology (Dr Lowe), University of Wisconsin Center for Health Sciences, Madison. Ms Ellerbe is now with Harborview Medical Center, Seattle. Reprint requests to Department of Surgery, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706 (Dr Demling).
show typical appearance of sloughing or Whitish gray exúdate is seen overlying that look like second-degree burns.
Left chest and
arm
epidermal necrolysis. these
areas
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/31/2015
the patient was relieved of much pain. With the patient under ketamine anesthesia, wound debridement and pigskin application was performed for the next four days. After this period, because of improved patient cooperation and less pain, narcotics were adequate for wound care. A feeding tube was placed on the day of admission and a high-protein, high-caloric solution was infused by continuous drip to equal her calculated daily caloric requirement of 3,400 and protein requirement of 200 g. Vitamin C, zinc, and therapeutic multiple vitamins were also added. High-dose vitamin A was not given because of its effect on steroid activity. A skin biopsy specimen taken to determine the level of epidermal sepa¬ ration showed necrosis of the upper four to five epidermal cell layers, with cleavage occurring mainly at the suprabasal epidermal layer. These changes were those of drug-induced TEN. Results of direct immunofluorescence skin studies with antihuman IgG, IgM, IgA, and complement C3 on frozen sections were
negative. The patient's
condition rapidly improved and she was able to walk without assistance after one week. Two weeks after admis¬ sion, the wounds were healed, her serum albumin level returned to 3.9 g/dl, and she was able to maintain proper nutrition without supplemental tube feeding. She continued to have some visual difficulties because of damage to the cornea. Hydrocortisone was gradually discontinued with no evidence of new disease.
COMMENT
The prognosis of TEN depends on the etiologic factors. Most children with staphylococcal-induced TEN will recover. Drug-induced TEN, with its deeper plane of epidermal cleavage, has a mortality reported at 20%,2 the major cause of death being infection. Differentiation between the two disorders is best made by history and skin biopsy specimen. Toxic epidermal necrolysis has been associated with other disease states such as irradiation," graft vs host reactions,' and fumigants.4 Sometimes no apparent cause can be determined. The characteristic skin tenderness is classic, and the condition has been previously called the "scalded skin syndrome." Drug-induced TEN is often treated with large doses of corticosteroids for systemic effect, but Lyell- said that there is disagreement about the absolute need for this treatment. Corticosteroids for systemic effect probably should not be used to treat staphylococcal-induced TEN when appropriate antibiotics are the preferred treatment. Generally, patients suffering from this group of disease states have been managed solely by a dermatologie or general medical service with general nursing care. However, as seen in this patient, the problems of infection, providing proper nutrition, pain, and emotional instability that are due to the loss of epidermis are identical to those seen in a patient with major burns. Because these types of '
problems are managed effectively and routinely by a burn service, these patients should be treated in a burn unit. It is there that infection is controlled by vigorous wound care. This includes active debridement and the use of topical antibiotics or biologic dressings to control surface coloniza¬ tion. To accomplish burn debridement, large doses of narcotics are necessary. We have found 4 mg/kg of intra¬ muscular ketamine hydrochloride to be very safe and effective in controlling pain. The magnitude of the nutritional support necessary to control the negative nitrogen balance in the burn victim has only recently been appreciated." Several formulas are
available to estimate caloric needs; we use the Curreri formula.7 The minimum caloric intake is calculated by the sum of 25 x weight in kilograms and 40 x percent body surface burn. Protein needs are two to four times the body weight (kg), depending on existing depletion. Children require more calories and protein than calculated by these formulas because of continued growth needs." It has been well demonstrated that intensive nutritional support greatly decreases morbidity and mortality of persons with burns. A second-degree burn that these dermatologie disorders may produce is extremely painful, particularly if left exposed to air as in the patient described here. Simply covering the area with a topical antibiotic cream will decrease the discomfort. However, large amounts of nar¬ cotics will still be necessary. A major advance has been the use of biologic dressings." This includes homograft or cadaver skin, heterograft or currently, pigskin and most recently, amnotic membrane. When the open areas are covered, there are not only dramatic decreases in pain, but also in caloric and evaporative losses. These tissues also have important antibacterial properties," the exact mecha¬ nism of which is still undetermined. Because of the chronic nature of convalescence from burns or major skin loss, tremendous emotional support is necessary. Patients can tolerate a considerable amount of pain if they understand its cause and the time course of recovery. This is well recognized by members of a burn service. A psychiatrist is usually assigned to a burn unit to help with this support. Once cooperation is lost because of excessive pain and fear as in the patient described here, recovery is greatly prolonged. With current burn care technique, not only survival, but patient comfort can be substantially improved. We there¬ fore believe that the combination of the knowledge of the dermatologist with the expertise of the burn service is necessary to obtain optimal results with TEN.
References 1. Amon RB, Dimon L: Toxic epidermal necrolysis. Arch Dermatol 111:1433-1437, 1975. 2.
Lyell A: A review of toxic epidermal necrolysis. Br J Dermatol 79:662\x=req-\
671, 1967.
3. Peck GC, Herzig GL, Elias PM: Toxic epidermal necrolysis in a patient with graft versus host reaction. Arch Dermatol 105:561-569, 1972. 4. Radimer GF, Davis JF, Ackerman AB: Fumigant-induced toxic epidermal necrolysis. Arch Dermatol 110:103-104, 1974. 5. Moncrief JA: Burns. New Engl J Med 288:444-454, 1973. 6. Davies JWL, Liliedahl SO: Metabolic consequences of an extensive
burn, in Polk HC, Stone HH (eds): Contemporary Burn Management, Boston, Little Brown & Co, 1971, pp 151-170. 7. Curreri PW, Richmond D, Marvin J, et al: Dietary requirements of patients with major burns. J Am Diet Assoc 65:415-417, 1974. 8. Holli BB, Oakes JB: Feeding the burned child. J Am Diet Assoc 67:240\x=req-\ 242, 1975. 9. Artz CP, Rittenbury MS, Yarbrough DR: An appraisal of allografts and xenografts as biological dressings for wounds and burns. Ann Surg 175:934-938, 1972.
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/31/2015
