I have no financial conflicts of interest to disclose for our presentation today. So there are several different types of acute and chronic drug-induced skin reactions. On the table on the slide here, I've highlighted some of the acute drug-induced skin reactions and the potential medications that could have caused those reactions. For the purpose of the presentation today, I will be focusing in on Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis Syndrome, which I will be referring to as SJS-N10 for the remainder of the presentation. SJS-N10 is classified based off of body surface area involvement. If a patient has less than 10% body surface area involvement, they're considered to have SJS. There's also SJS-N10 overlap syndrome, which is when a patient has 30, or excuse me, 10 to 30% body surface area involvement. And then 10 is when there's greater than 30% body surface area involvement. The exact pathophysiology of SJS-N10 is not fully understood, but it is believed that it can be induced by a medication or a drug presented to a keratinocyte, causing activation of CD8 T-cells, and also natural killer cells, natural killer T-cells, and activation of cytotoxic T-lymphocytes. When those cells are activated, it causes the production of granulysin, which is a key mediator in the pathophysiology of SJS-N10. When granulysin is released, it can cause a keratinocyte cell death in necrosis, which leads to that hallmark characteristic of the sloughing of the skin that we see and the skin detachment from the epidermis. It can also lead to blister fluid formation. There are several medications that have been associated with SJS-N10. On this slide here, I've highlighted some of the more common medications that have been reported in the literature. On the left-hand side are the strongly associated medications, some of the more common ones being allopurinol or anti-epileptic medications, such as lamotrigine or carbamazepine, and then even some antimicrobials, such as sulfamethoxazole. One thing to keep in mind when you're trying to identify the medication cause of SJS-N10 is the timing. So typically, SJS-N10 will present within the first eight weeks of initiating a medication therapy. So if a patient presents after eight weeks of initiating that therapy, it's probably not that medication causing it. It can be highly variable on when they do present. They can typically, the onset is anywhere from four days to four weeks. And then in about a third of cases, there's actually no readily identifiable cause. The management of SJS-N10 is largely supportive care with surgical debridement, fluid and electrolytes, good nutrition, pain control, and temperature regulation. It's also important to transfer the patient to a burn center or a center that's capable of taking care of these types of patients, as it has been shown to improve patient outcomes. It also, again, we would want to make sure that we take a good medication history to examine if there are any potential medications that have been initiated within the past eight weeks. And if there is one that is identified, it is important to stop it as soon as possible or taper it as quickly as possible. When we're assessing the prognosis of our patients, there is a tool called the SCORE-10 score. This will predict their mortality risk, and it involves seven different variables that are listed there on the slide. A patient would get one point for each variable that they meet or each criteria that they meet, and then it produces an estimated mortality risk. So while the primary management of SJSN10 is supportive care and supportive measures, there has been some immunomodulatory therapies that have been examined for potential treatment options, one of those being corticosteroids. So corticosteroids have anti-inflammatory and immunosuppressive properties. It's well known that they inhibit cytotoxic T lymphocytes, which is one of the cell lines that is involved in SJSN10. Another potential immunomodulatory therapy would be IVIG or intravenous immunoglobulin. It has been shown to inhibit receptor-mediated cell death for keratinocytes, and so thereby decreasing the amount of skin involvement that we see. Another potential option is cyclosporine. Cyclosporine is a calcine urine inhibitor and has been well described for treatment of diseases such as graft-versus-host disease, which as we've learned more about the pathophysiology of SJSN10, we actually think it may closely resemble GVHD. So cyclosporine can inhibit CD8 T cells and also cytotoxic T lymphocytes. And finally, Atanercept is a tumor necrosis factor alpha inhibitor, or TNF alpha inhibitor, and it has also been examined and has been shown to inhibit granulicin production, and granulicin is one of the key mediators in the pathophysiology of SJSN10. So while these potential medications could be used for SJSN10, they're actually not widely utilized in burn centers across the United States and across the world. This study by Richard and colleagues highlights that fact and surveyed 31 burn centers in the United States. 30 of the centers did have protocolized treatment regimens for their SJSN10 population, however, they did not widely utilize immunomodulatory therapies. If they did utilize these therapies, the most common one that was used was actually IVIG. So the reason that these therapies are probably not widely utilized is due to the lack of strong evidence supporting their use. Due to the fact that SJSN10 is such a rare condition, it's very difficult to get large randomized controlled trial studies to evaluate these therapies. The study on the slide here is a retrospective study of patients with SJSN10 enrolled from the prospective EuroSCAR study. The EuroSCAR study was a study that was looking at risk factors for SJSN10. So this analysis here is a subgroup of patients who received immunomodulatory therapies and they were specifically enrolled from France and Germany. And so they actually were, their primary outcome was looking at the mortality difference in patients who received immunomodulatory therapies, specifically IVIG or corticosteroids compared to supportive care alone. They had 281 patients, a majority of their patients, or the highest number of their patients had SJS. They did not actually report a score 10 score, so we do not have an index of severity of illness. They did, however, report medication dosing, which a lot of studies do not. So their median IVIG dose was 1.9 grams per kilo for three days and their corticosteroid max dose was 250 milligrams of prednisone equivalent for four days. And they actually did not see any mortality benefit with either therapy, with IVIG or steroids. Another thing to note, there are several weaknesses of this analysis. One being that when they analyzed their data, they had 40 patients that received both therapies, the IVIG and the steroids, and they actually included those patients in both treatment groups for their regression analysis. So this could have some overlap. A follow-up study is the Regiscar study. This is a retrospective cohort study from January 2003 to March 2007. They had a very similar outcome as the previous study in a similar patient population in that most of them were from France and Germany. And they were looking at mortality difference between IVIG or corticosteroids compared to supportive care. It was a larger study than the previous study with 442 patients and about 50% of their patients had SJS. The median corticosteroid dose that was utilized was 75 milligrams in France and 250 milligrams in Germany. And they had an overall mortality at one year for the TEN population of about 49%. Again, they did not find any significant difference in mortality between patients who received IVIG and corticosteroids. There again are several limitations of this study. The authors actually noted that there were significant differences in treatment practices between the two countries. A majority of the patients who received corticosteroids were actually from Germany, and the doses ranged were highly, highly variable. Another potential therapeutic option is Etanercept. And so this study is one of the few studies that actually examined Etanercept and compared it directly to prednisolone. And patients either received Etanercept 25 or 50 milligrams twice weekly versus prednisolone 1 to 1.5 milligrams per kilo per day. And the primary outcome was looking at the time required to complete skin and oral healing. They did see a significant decrease in the amount of time to healing in the patients who received Etanercept. And this was specifically in the patients who had a body surface area involvement of greater than or equal to 10%. Another interesting finding from this study was that they actually saw an increase in GI hemorrhage in patients who received the prednisolone. A second study looking at Etanercept was done by Zhang and colleagues, and it was conducted in China and Taiwan. It was a retrospective review of 242 patients. This one actually had three different arms of the study. So they either received corticosteroids, corticosteroids plus IVIG, or corticosteroids and Etanercept in combination. So it is slightly different than the previous study in that they used Etanercept with corticosteroids. Of note, most of the patients did receive corticosteroids at 196 patients. And only 25 patients were in the corticosteroids plus Etanercept group. Also to note, the score 10 mortality in the patients who received Etanercept was 14.4%. So it was numerically fairly high, but yet they did not actually observe any mortality in that group. When looking at the results of the study, the time required to healing was significantly shorter in the patients who received Etanercept compared to the other two treatment groups. They also did an analysis looking at risk factors for mortality, and they showed that patients who received high-dose steroids at methylprednisolone 1.5 and 2 milligrams per kilo per day had significantly higher rates of mortality. So again, this is highlighting that there could maybe be potential harm with high-dose steroids. So due to the fact that a lot of the studies are very small and retrospective observational in nature, there have been several meta-analyses that have been conducted to try to examine the potential therapeutic effects of immunomodulatory therapy in the SJS and TEN population. The first study by Zimmerman actually did see a significant decrease in mortality with corticosteroids and with cyclosporine. This was one of the first larger studies to examine cyclosporine outside of case reports. The second study by Torres and Navarro, they sought out to actually compare their actual mortality versus the mortality predicted by the SCORE10 score. And so they saw that there was a significantly decreased actual mortality compared to what the SCORE10 predicted for patients who received cyclosporine, IVIG, plus corticosteroids and etanercepts. However, in contrast, the third study on this slide actually showed no difference in mortality. But they also did find that their actual mortality in patients who received IVIG and corticosteroids was lower than what the SCORE10 score predicted. So one thing that has, as we've been using the SCORE10 score longer, we've realized that it may actually overestimate what the actual mortality is. And so when it's a little more challenging to interpret the results of some of these studies because we don't know if it's an error with the way the score is calculating the mortality or if this benefit is actually truly from the immunomodulatory drugs. Another meta-analysis from Patel and colleagues that was published in 2021, again, did see some potential benefit with mortality in patients who received cyclosporine compared to IVIG alone or compared to supportive care. They also saw that the combination therapy of corticosteroids and IVIG did decrease mortality compared to IVIG monotherapy. And then in contrast, there was recently a Cochrane review that was conducted in 2022. They used much more rigorous criteria for what studies they examined and what they include in their meta-analysis. So they only included nine studies, and they saw that there was no disease-specific mortality difference between any of the immunomodulatory therapies. However, they did make note that TANRCEPT may be a potential therapeutic option and definitely warrants further study as they saw that there could be a potential mortality decrease when you compare it to corticosteroids. And the results of that are from the Wang study that was presented previously in the presentation. So overall, in summary, there is not enough data to recommend routine use of immunomodulatory therapies in SJS N10. And one of the reasons is that the dosing, the timing of the medications, which medications to use, is all incredibly highly variable. And most of this data, as I said, is very small populations and even case series or case reports. I would use caution with giving high doses of corticosteroids as there has been several reports of potential harm associated with that therapy. And I thank you. Thank you, Kelly. All right. Our next presenter is Carrie Sona. Carrie is a clinical nurse specialist at the Surgical Burn Trauma ICU at Barnes-Jewish. And her talk is Protecting the Skin, a Detailed Guide to Good ICU Care. Good morning, everybody. Thank you for having me. I started as a new graduate nurse in a six-bed burn unit in 1987. And I've been taking care of patients with complex wounds since that time. I became a clinical nurse specialist in the 2000s, so I've been a CNS for 23 years. And that's where I work. Do I have to hit this every time? Oh, no, wait, no, you should just be able to hit the button, hit the left button. Okay, no disclosures, other than I've taken care of a lot of patients with wounds. The objectives for the talk, obviously, I'm going to share the nursing lens with you about taking care of sick people with a lot of complex wounds, look at clinical assessments and the interventions that we do for patients. I'm going to start with a couple of cases. I'm not going to go in depth, but just to pique your interest and show you some of the kind of people that we take care of. This year, we had a kid who was a college kid. He was 21 years old. You can see his interest. He loves racing. He loves going fast. He loves planes. Both of his parents are pilots. He was a trained pilot. He was riding his motorcycle very fast. And he ran into the back of a semi-truck at about 100 miles an hour. And he was thrown the distance of a football field. So imagine that, found in a cornfield. And he was actually neuro-intact, GCF 15, intubated at the scene, and came actually to an outside facility. I'm definitely not going into all of his injuries, but he had multiple orthopedic injuries. He had pelvic fractures. He was bleeding. He had a riboic catheter inserted. He received massive transfusion. And he was transferred to our level one trauma center. In our unit, he continued to get resuscitated. He actually lost his pulses. They took out his ribo at the bedside, and they did four compartment fasciotomies, took him to the OR. And we were busy saving his life. The wound that he had is obviously, I have some trigger warnings. I have some pictures coming. A large perineal degloving injury this kid had. Went to the operating room multiple times for multiple procedures. He had fecal diversion and just multiple washouts, debridements, repair of his injuries. He was in our hospital for a very long time. But the things that really apply to wound care and things we've been talking about so far, I think, obviously, his malnutrition was prevalent. And it isn't always because we weren't doing a good job feeding the kid. You saw how many operations he had. Every time he goes to the operating room, his feeding is interrupted. We follow all of the protocols where we catch up. We do feeding. We put internal feeding in a small bowel tube and an NG. We feed people up until the time of their operations. Suck their gut out. Take them back. Catch up when they get there. Try to feed him orally when he wasn't intubated or on the ventilator. Give him TPN. Multimodal feeding and doing everything you can. But you can't have that many operations and disruptions and be that ill and get adequate internal nutrition to heal those wounds. Obviously, we did all of those things. Clearly, he had some depression. He's a 21-year-old college kid dealing with this life-altering thing. Wonderful, supportive parents who were from out of town and had multiple infections. This is him six weeks post-injury. And then at three months, diverting colostomy. Grafts have started to happen. Some donor sites on his thighs. And then just another case to set the stage for the nursing lens of taking care of people with complex wounds. We had a patient who'd had a previous injury, leaving him tetraplegic, who had exposed hardware in the base of his spine. He actually had friends that were using tools on his back to deal with this thing. You can't make this stuff up. Anyway, I just highlighted a case of we did really a lot of things correctly. In this case, we did not really do a lot of things correctly. No one's perfect. This patient was not adequately, there was not a good care plan preoperatively for this patient. And the anesthesia team felt that they were going to extubate him post-op and we were going to nurse him prone for this flap that he was going to have. Well, guess what? He didn't get extubated. And so he was, his flap looked great, and he was prone in our unit. But he proceeded to be in our unit for five weeks. They didn't have adequate internal access. He was on a regular bed service on arrival. They told us not to turn him. There were literally places on his body where we couldn't touch him to take care of him. People still make urine in stool. So he luckily did have an ileal conduit and a colostomy from his previous tetraplegia. But his airway was suboptimal. So poor preop care, preop coordination truly impacted this patient's outcome. So again, just from a nursing lens, we look at, obviously, the whole patient. We have to take care of the whole patient. The common tools that we use to screen for pressure injuries are well known, I'm sure, to all of you in the room. The United States tends to use the Braden scale the most often. The elements of that are the sensory status of the patient, moisture, a very large problem, especially in surgical ICUs. Patients are wet and drained. And we are very good about early mobility. But the patient's activity level, can they move on their own, nutrition, as we mentioned, friction, and shear. There are newer models that are being developed that are predictive, taking into consideration things like oxygenation, perfusion, multiple pressors, things like that. The whole NPIAP, National Pressure Injury Advisory Panel, investigating are things truly, are there pressure injuries that are not preventable? I vote yes. But proving that case has been challenging. Other things that we look at that I think have come out in the literature as the most important factors for who is going to get a pressure injury are the reduced mobility, perfusion alterations, no matter the cause, as listed on the slide, and a previous history of pressure injuries and other wounds. Those are falling out as very high predictors of this patient's going to develop another pressure injury. And then other long operating room times, multiple operations, being old, long length of stay. In our unit, our pressure injury rate where I work is about 10%. I wish it was lower, just telling you a fact. But a lot of our patients are there for a very long time and have multiple operations. And then male gender, oxygenation, as was mentioned, and then multiple comorbidities, steroid use, COPD, and obesity. It is important to perform a risk assessment as quickly as possible. And then getting a patient on a good bed surface early. And you would think that that would be easy, but it's not. So a patient is very sick, like I just mentioned. That kid's sickness, our priority was not what bed was he on, right? So he's bleeding out. He's not well perfused. There's a lot going on. And when the patients are at their highest risk is when we have them laying flat, don't turn them, and they're on the poorest bed surface possible. So we have an algorithm. I'm sure all of you have algorithms where you work. It starts with a scoring system. It takes into consideration the patient's weight, spine stability, and then pulmonary complications, other things that you might want to consider. So again, you'd think it's easy, but it's really hard. We try to have, we don't have the resources that every one of our patients is on the most perfect, low air loss, moisture controlled, temperature climate controlled bed surface. I wish we did have the resources for that. Some of our bed fleet is incredibly old, and I'm sad about it, but it's a fact. And then getting the patients from the ER to the OR, and then if it doesn't happen in the OR, and then they come to us, and then we're going to CT, and then we're putting lines in them. Sometimes the logistics of getting people on a good bed surface is very painful. And then don't forget the chair, using pressure reduction when patients are immobilized, doing micro shifting, and things like that. Again, all of these things are happening while we're actually really taking care of a super sick person at the same time. So it's very important for us. We're taking care of the family. We're explaining things. We're traveling. We're giving medications. And it's important that we not only do those things on admission, but on every handoff with another caregiver. Two nurses should look at that, and not just, oh, yeah, their backside looks fine. Well, sometimes things can go unnoticed. And four sets of eyes are better than two. And we also use our tele-ICU to help us with that. We'll hit the button. And if we don't have the manpower and personnel that's another nurse, which I haven't even mentioned yet, the staffing shortage, manpower, agency nurses, some of these people that we're getting to staff in our units, they've not taken care of sick people like this before. And now they're dealing with things that they do not understand and have never seen. We do a lot of photography. We document what we see. We like to float people's heels. We use boots. I talked about that. I wish that we could have better fecal diversion that was not internal that led to GI bleeding. One of the products that we use all the time is no longer available due to supply chain shortages that we've now been facing with COVID-19 pandemic. So it's just a whole new world of challenges that we're all facing to try to protect our patients. We use external urinary catheters when we can. Again, nutrition, I can't stress enough the importance of that. We have a lot of tube and drains. And then we obviously consult our wound and ostomy nurses to help us as needed. She already mentioned this, so I don't have to go into it. But when we're describing wounds, you should use the patient's head, that measurement first. So you use length, width, and depth. And then always, all wounds should have a depth marking. If they don't have depth, put zero. And then you should be documenting the percentage of slough or eschar on a wound bed. And she went into that already. Again, local wound care, I think of it more as an art than a science. Obviously, there's science. But I really think that vigilance is one of the most important things. Looking at wounds often, taking care of them, changing things when it's not working. I could go into every one of those products, and we would be here all day. And I'm not going to do that. I'm going to mention just some other things that nurses take care of. Obviously, we have a lot of surgical incisions, tubes and drains. The kid on the bottom right was a young guy who was changing a, he was a mechanic, and working under a diesel truck that fell off of the jack and smashed him. So that, obviously, is a less common type of wound. But we get some pretty big wounds. Other things, again, venous stasis ulcers, arterial diabetic ulcers. Moisture-associated dermatitis and incontinence-associated dermatitis are incredibly challenging and common where I work. Pressure injuries and then trauma. This management of skin tears and blisters. Again, I'm not so confident that it matters as much what you put on them. Keep it moist. Keep it clean. Don't put tape on people that skin is falling off. Use a coband, a wrap, something that's not going to cause more trauma. You can use arm protectors for people with frail skin to prevent from hitting it in the bed rail and things like that. Unroofing blisters, we generally keep them intact, but they're going to pop eventually. So leave the biologic covering if you can. If they're large surface area, they end up usually getting debrided. Again, I mentioned incontinence-associated dermatitis and moisture-associated dermatitis. The etiology often starts as moisture, but then over time, sick people lying in a bed, it becomes a combination of moisture and pressure. The shape of pressure injuries is normally more linear. Moisture is more diffuse pattern. And then we use a lot of zinc. Some products have more zinc than others. There was a lovely product, I don't have stock, but it's a spray product. Amazing. Game changer. No longer available. Supply chain shortages because of the pandemic. So we're hoping it comes back. And then if, obviously, people have fungal infections, add an antifungal to the mix. Insert whatever product here. The only comment I will say about this, and we use it as prophylaxis on bony prominences, we do discourage the use if your patient is incontinent of stool to keep that dressing there, because then it pools in the dressing, and now you're creating an issue with that. So pick the dressing appropriate for what you're doing. Some of them have silver. Fantastic. Polymem is a product that, again, no commercial buy-in. We use a lot of it. It has better qualities that help the wound bed. We really like it. It seems to work well. They now make a trach dressing, which is fantastic. And then there's a newer product called Drautex that we've just started using. We've actually had some of our surgeons start doing suture-free trachs because of the pressure injury problem that we have from tracheostomy at our institution. The ENT surgeons are obviously not those surgeons, because they like theirs tight. And then just, again, you can trim these things. There's many different qualities of these dressings that are amazing, but it would take forever to go through all of the products. Another common nursing challenge that we face is skin on skin. So the patient on the left is actually the back of their neck, where their neck folds touch. We get a lot of really tight trach ties that do the same thing. The pannus of women under their breast tissue, we use a product called InnerDry. But again, no commercial allegiance, just whatever works. I think that if the COVID pandemic did anything for us, it's helped us understand prone positioning and the risk of patient skin. So putting people on a good bed surface, padding areas that are bony prominences, positioning them well, managing moisture, and whatever product you're using following those guidelines. Pressure injury staging, I'm obviously not going to go through that. I'm sure everyone has seen it. But obviously, stage 1 through unstageable DTIs, and then medical device-related pressure injuries. Again, just not the time to go through all of these things. Stage 1 and stage 2, we generally use a zinc product. And then stage 3 and stage 4, we fill the space. Negative pressure wound therapy, things like that. I just wanted to show a couple of pictures of how you can be surprised how wounds evolve over time. So if you just look at the heel on the left side of the screen, you might think, oh, that's going to be awful. But over time, it evolves. And that wound healed fine, no issue. Here's a case that didn't go that way, different trajectory, bruised DTI, evolved over time with eschar, and then obviously needs surgical debridement. Device-related breakdown, nurses obviously are at the forefront of looking at people, caring for them, taking care of them. The majority of breakdown that we have in our unit is device-related breakdown. And it happens quickly. A patient will go for an operation. Anesthesia strung the NG up over their nose. They come back, they have a pressure injury on their nare. These examples is an ET tube on the tongue. And you can see how it evolved over time. And a forehead oxygen center, a sensor, the trach tube, getting sutures out as quickly as possible, getting devices out as quickly as possible, rotating them when you can. This is a cervical collar in a patient's chin. Clearly, we needed to shave him. But that's just showing you that. The feeding tubes with these protrusions, these peg tubes drive me bananas. I don't know why they have to be so protruding with those buttons that stick into the patient's skin and are sutured tightly on a new tube. Very challenging. Anchor fast securement of ET tube over the ear, NG tubes going up. We use a lot of bridling. You can see in this lower right example that the bridle caused a pressure injury from even just having that twill under it. So always vigilance, hard. We use a stress loop taping method to allow the tube to float in the nares. Again, we have other specialty wound care available to us. Negative pressure wound therapy with or without irrigant. We do a lot of leach therapy for patients that have replanted limbs. Hyperbaric oxygen therapy, we actually don't have inpatient HBOT at our facility. We have it for outpatient. So more of our wound center. And then we have also done a fair amount of MAGA debridement therapy. That kid that I showed you that had gotten smashed with the big truck falling on him, we did MAGA debridement therapy on him. Just a couple of things that are probably nursing-specific bugs, but I'm going to say them because you asked a nurse to talk, is that when providers have a strong opinion about what should be done for their patient, they should put orders in that reflect that. So again, we have nurses that have never taken care of some of these people now. We have agency nurses that were nurses for a year, and they're traveling across the country. And now they're taking care of really sick people. They've never done some of this before. So if you have a really strong treatment plan, you should probably translate that to a medical order in the chart and not just think people are going to know what you like. One minute left. The other thing is that we actually have a lot of tubes and drains. Imagine being a new nurse, never taking care of a patient. And with all these tubes and drains, we label them so they know what they are. Surgical drain, feeding, we fed the wrong thing. If you can make a mistake, we've done it. But it's not because people are ill-intentioned. It's because they don't know. So make sure that you put good orders in and communicate. OK, I'm going to make it. So just to go back to the cases and tell you how things turned out. That patient obviously had six months in the hospital in acute care in the ICU in the floor and then went to inpatient rehab. The risk of his injuries to his skin, bleeding, low blood pressure, pressures, moisture, immobility, oxygenation, things that were great, optimal bed surface, fecal diversion, obviously a lot of negative pressure wound therapy, nutrition, education, and a lot of emotional support. Here he is eight months post-injury. On the left, he still had some open wounds on his bottom. And then this is him and the nurses taking care of him. Took him outside a lot. He is a pilot. We all decorated. Those aren't the planes. But we all decorated paper airplanes. And everybody made a paper airplane, every discipline. Decorated his room with those things. And then when his parents put on his carrying bridge, just the impact of being there emotionally for people, going through this trauma, both the patient and the family, cannot be under communicated. And the toll that it takes and the bonds that people make. And it definitely left an impact on his family. You can see how thin he is. And then that's it. I wish everybody could float and not have anything touching their skin. Thank you.

Stevens-Johnson Syndrome

Toxic Epidermal Necrolysis Syndrome

supportive care

medication identification

immunomodulatory therapies

specialized burn centers

multidisciplinary approach