SAEM Clinical Image Series: Painful Weeping Rash


A 67-year-old nontoxic appearing male patient with a history of coronary artery disease, hyperlipidemia, transient ischemic attack, gout, renal colic, and squamous cell carcinoma presents with concern for multiple new painful lesions on his body. The rash first appeared five months ago but disappeared for some time before reappearing. It has worsened over the past few weeks. He has pain, erythema, pruritus, and urticarial, blistering, crusted lesions. He has had clear drainage from ruptured blisters. His only recent change in medication is an increase in his allopurinol (initiated four months ago; increased three weeks ago). He has tried Benadryl and steroids with minimal relief and is quite frustrated as this is his fourth emergency department visit for this complaint.

Skin: Multiple areas of 1-3 cm bullae (both tense and flaccid as well as open/ulcerated) on the trunk, groin, axilla, inguinal folds, palms, and dorsum of feet, not on soles; papules coalesce into annular plaques; no mucosal involvement

None. Complete blood count (CBC) from seven days prior showed normal counts and 9.4% eosinophils.

This patient has bullous pemphigoid. Also included on the differential is bullous lupus erythematosus, urticaria, DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), epidermolysis bullosa, and erythema multiforme.

Diagnosis may be made through clinical recognition of the typical features. The workup for a definitive diagnosis begins with histopathologic direct immunofluorescence from a skin biopsy of the edge of a blister and the surrounding normal-appearing skin, which is then confirmed with indirect immunofluorescence of the patient’s serum.

Take-Home Points

  • Bullous pemphigoid is a chronic, inflammatory, subepidermal, blistering disease. It is the result of an attack on the basement membrane of the epidermis by IgG +/-IgE immunoglobulins and activated T lymphocytes.
  • It primarily affects elderly individuals in their 50s-70s, with an average age at onset of 65 years, and is often associated with stroke or dementia.
  • The most common treatments for bullous pemphigoid are anti-inflammatories (topical and oral steroids), immunosuppressants, and doxycycline. Treatment regimens are aimed to minimize the systemic side effects of the treatment itself, while also decreasing inflammation, blister formation, and autoantibody production.
  • Oakley, A. Bullous pemphigoid. Jan 2016. [Online] Available at:
  • Chan, L. Bullous Pemphigoid. Oct 2020. [Online] Available at:


By |2021-12-02T13:13:48-08:00Dec 6, 2021|Dermatology, SAEM Clinical Images|

Dose Order Matter? Which Antibiotic to Give First for a Bloodstream Infection


Early antibiotics are recommended for treatment of many infections, including patients with sepsis or septic shock [1]. Critically-ill patients and those with a suspected infection at risk for severe illness are generally administered two (or more) empiric antibiotics in the emergency department (ED) which cover a wide range of potential pathogens. A typical approach includes utilizing a broad-spectrum antibiotic (frequently a beta-lactam such as cefepime or piperacillin-tazobactam) plus an anti-MRSA agent (typically vancomycin).

Early in the patient’s hospital stay they may have limited IV access, so the question often arises as to which antibiotic to give first, the broad-spectrum antimicrobial or the anti-MRSA agent. Additionally, though the overall risk of an allergic reaction is relatively low with most antimicrobials, when multiple agents are given simultaneously it can be difficult to ascertain which one may have caused a reaction and lead to incorrectly documented allergies, so it can be important to consider if the initial doses should be administered separately. However, there isn’t strong data to guide practice in terms of giving the initial antibiotics concurrently vs consecutively, from an allergy perspective. To further complicate the issue, patients may also develop delayed reactions so a strong causal relationship cannot always be determined. In practice, there are times (increasingly so with rising ED patient volumes) when we give antibiotics one at a time simply for logistical reasons. So that begs the question, which antibiotic should be given first?


In patients with sepsis or septic shock, early antibiotics significantly decrease mortality [1]. This relationship is strongest for patients with septic shock, where the odds of in-hospital mortality was increased by 1.04-1.16 for each hour antibiotics were delayed [2-4]. Notably, broad spectrum antibiotics are deemed such as they cover both gram positive and gram negative pathogens, therefore the addition of an anti-MRSA agent contributes a relatively smaller amount of coverage and is primarily targeted at resistant gram-positive bacteria. Additionally, gram-negative pathogens tend to cause a higher degree of illness and mortality, so it would be reasonable to give the broad-spectrum antibiotic first [5-7]. As both cefepime and piperacillin-tazobactam are recommended to be infused over 30 minutes (though this can vary based on institutional policies) and vancomycin is typically infused over 1 hour for each gram, if vancomycin is administered first, patients may wait hours to receive a broad spectrum agent.

A recent study now supports this practice. This is an observational trial which evaluated 3,376 patients with a blood stream infection, 2,685 patients received a beta-lactam first and 691 patients received vancomycin first [8]. They found that patients who received a beta-lactam prior to vancomycin had significantly improved 48-hour and 7-day mortality. Further review of this article may be found on the JournalFeed blog post.

Bonus tip: Having antibiotics stocked on the unit reduces time to administration [9].

Bottom Line

  • Antibiotic delays lead to increased mortality, especially in patients with septic shock.
  • For patients with a suspected bloodstream infection, administering the broad-spectrum antibiotic first, instead of the anti-MRSA agent, has the potential to reduce mortality at 48 hours and 7 days. This should be the general approach for treatment of all infections when two or more antimicrobial agents are indicated.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.


  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143. PMID: 34605781. doi: 10.1097/CCM.0000000000005337.
  2. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376(23):2235-2244. PMID: 28528569. doi: 10.1056/NEJMoa1703058.
  3. Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196(7):856-863. PMID: 28345952. doi: 10.1164/rccm.201609-1848OC.
  4. Peltan ID, Brown SM, Bledsoe JR, et al. Ed door-to-antibiotic time and long-term mortality in sepsis. Chest. 2019;155(5):938-946. PMID: 30779916. doi: 10.1016/j.chest.2019.02.008.
  5. Abe R, Oda S, Sadahiro T, et al. Gram-negative bacteremia induces greater magnitude of inflammatory response than Gram-positive bacteremia. Crit Care. 2010;14(2):R27. PMID: 20202204. doi: 10.1186/cc8898.
  6. Alexandraki I, Palacio C. Gram-negative versus Gram-positive bacteremia: what is more alarmin(G)? Crit Care. 2010;14(3):161. PMID: 20550728. doi: 10.1186/cc9013
  7. Morgan MP, Szakmany T, Power SG, et al. Sepsis patients with first and second-hit infections show different outcomes depending on the causative organism. Front Microbiol. 2016;7:207. PMID: 26955367. doi: 10.3389/fmicb.2016.00207.
  8. Amoah J, Klein EY, Chiotos K, Cosgrove SE, Tamma PD, CDC Prevention Epicenters Program. Administration of a β-lactam prior to vancomycin as the first dose of antibiotic therapy improves survival in patients with bloodstream infections. Clin Infect Dis. Published online October 4, 2021:ciab865. PMID: 34606585. doi: 10.1093/cid/ciab865.
  9. Lo A, Zhu JN, Richman M, Joo J, Chan P. Effect of adding piperacillin-tazobactam to automated dispensing cabinets on promptness of first-dose antibiotics in hospitalized patients. Am J Health Syst Pharm. 2014;71(19):1663-1667. PMID: 25225451. doi: 10.2146/ajhp130694.

SplintER Series: I Declare a Thumb War

Gamekeeper's Thumb


A 39-year-old female presents to the emergency department with right thumb pain after falling in a skiing accident. On exam, there is mild swelling and tenderness on the ulnar aspect of the 1st MCP joint. Additionally, there is laxity with valgus stressing of the 1st MCP joint. An x-ray is obtained and shown above (Image 1. Provided by Alex Tomesch, MD).


SAEM Clinical Image Series: Chronic Back Pain

A 52-year-old male with a past medical history of prostate cancer status post radiation therapy 10 years prior presents to the emergency department (ED) with the chief complaint of low back pain worsening over the past year. He characterizes the pain as a “dull, aching stiffness” associated with decreased motility.

Vitals: BP 128/82; HR 72; RR 18; T 37°C

General: Alert and oriented

MSK: Decreased range of motion of the lumbar spine with flexion; Heberden’s and Bouchard’s nodes on multiple fingers

Neurologic: Within normal limits with no focal motor or sensory deficits appreciated; deep tendon reflexes 2+ throughout

Comprehensive metabolic panel (CMP), complete blood count (CBC), erythrocyte sedimentation rate (ESR), calcium, phosphorous, and urinalysis all within normal limits.

Prostate-specific antigen (PSA): undetectable

HLA-B27: negative

Diffuse Idiopathic Skeletal Hyperostosis (DISH).

The classic clinical presentation is an older male with increasing back pain and stiffness that is worse in the morning, as seen in 80% of affected individuals. Common labs are unremarkable in patients with DISH. Peripheral joint involvement is possible, especially in joints that are not normally affected by primary osteoarthritides, such as the foot and ankle. Heel spurs, Achilles tendinitis, and plantar fasciitis may be seen as well. Differentiating features of DISH compared to ankylosing spondylitis include older age of presentation, preservation of facet joints and disk spaces, and no association with HLA-B27.

This patient has an increased risk of spinal fractures. Thus, if an older patient with known DISH presents with acute back pain following minor trauma, the workup will require a comprehensive neurovascular exam and imaging of the entire spine due to the patient’s disposition to spinal fractures.

Take-Home Points

  • Diffuse idiopathic skeletal hyperostosis (DISH) is an occult noninflammatory disorder of unknown etiology characterized by calcification and ossification of spinal ligaments and entheses on imaging.
  • Diagnostic criteria include linear calcification and ossification along the anterolateral aspect of multiple consecutive vertebral bodies, most often seen in the thoracic spine and less commonly seen in the cervical and lumbar spines.
  • Therapy for patients with DISH is similar to that of chronic lower back pain: physical therapy, exercise, and symptomatic pain management with acetaminophen or NSAIDs.
  • Patients should be educated to monitor acute changes in localized spine pain or neurologic disturbances, as DISH predisposes patients to fractures, even from minor injuries.

  • Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. 1998 May;27 Suppl 1:S7-11. doi: 10.1016/s0720-048x(98)00036-9. PMID: 9652495.


By |2021-11-08T10:47:24-08:00Nov 22, 2021|Orthopedic, Radiology, SAEM Clinical Images|

SAEM Clinical Image Series: Pediatric Rash

pediatric rash

A previously healthy 8-year-old female presents to the pediatric emergency department due to a rash. Her symptoms started three days prior to presentation with a painful rash on her lower extremities. The rash subsequently spread to the buttocks and upper extremities, and she developed intermittent diffuse abdominal pain, a nonproductive cough, and pharyngitis. The patient denies subjective fever. Known sick contacts include the patient’s mother, who tested positive for COVID-19 two and a half weeks prior.


Vitals: T 98.5°F; HR 93; BP 115/68; RR 16; O2 sat 100% on room air

Constitutional: Well-developed and in no acute distress

HEENT: Normocephalic, atraumatic; moist mucus membranes; no conjunctival injection; posterior pharyngeal erythema without exudates; tonsils are three bilaterally; lips are not cracked; no “strawberry tongue”;

Neck: Normal range of motion; no lymphadenopathy

Cardiovascular: Regular rate and rhythm; normal heart sounds and pulses

Pulmonary: Effort is normal; normal breath sounds; no wheezing

Abdominal: Abdomen is flat; minimal tenderness to palpation without guarding; no organomegaly

Skin: Diffuse petechial rash and painful, palpable, nonblanching purpura in the dependent regions (most notable on the buttocks and lower extremities)

COVID-19: Detected

Complete blood count (CBC): WBC 10K, hemoglobin 13, platelets 469

Comprehensive metabolic panel (CMP): Na 138, K 4.1, Cl 103, CO2 26, BUN 7, Cr 0.38, Glucose 94, ALT 23, AST 26, Albumin 4.5

Lipase: 10

Urinalysis (UA): Normal

C-reactive protein (CRP): 3.4

Erythrocyte sedimentation rate (ESR): 24

Procalcitonin: 0.03

Fibrinogen: 363

BNP: <10

Troponin: 0.00

Ferritin: 83

Triglycerides: 37


  • COVID-19-Associated Multisystem Inflammatory Syndrome in Children (MIS-C): According to CDC criteria, patients must be under 21 years of age, with a fever higher than 38°C/subjective fever for longer than 24 hours, laboratory evidence of inflammation, severe illness requiring hospitalization, and two or more organ systems involved (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurologic), with no alternative plausible diagnoses and recent COVID-19 infection.
  • Immunoglobulin A Vasculitis (Henoch-Schönlein Purpura): According to the EULAR/PRINTO/PRES criteria, symptoms must include cutaneous findings (palpable purpura or petechiae without the presence of thrombocytopenia), plus at least one of the following: diffuse abdominal pain with acute onset, arthritis/arthralgia, renal involvement in the form of proteinuria or hematuria, or deposition of Immunoglobulin A seen on renal histology.
  • Kawasaki Disease: The diagnostic criteria include fever for five days or longer and four of the following: bilateral conjunctival injection, cervical lymphadenopathy, polymorphous rash, oral mucous membrane changes (including fissured lips, pharyngeal erythema or strawberry tongue), peripheral extremity changes (edema of the hands/feet or desquamation).

Immunoglobulin A (IgA) Vasculitis.

This patient presented with palpable purpura and petechiae without the presence of thrombocytopenia, as well as diffuse abdominal pain. The majority of cases of IgA Vasculitis are preceded by a respiratory pathogen, with the most common being streptococcus, staphylococcus, and parainfluenza virus. Although not well-documented due to its recent conception, COVID-19 is likely to be the cause of this patient’s vasculitis. Usual management of IgA Vasculitis is supportive care, with admission and specialty referral for complications including intussusception and glomerular involvement. Given the severity of the differential diagnoses, this patient was admitted to the hospital for observation and discharged the following day with close follow-up

Take-Home Points

  • COVID-19 can cause a variety of rashes in the pediatric population, and appropriate workup including inflammatory markers, complete blood count, and comprehensive metabolic panel must be initiated to rule out severe disease. Consider obtaining a troponin, EKG, chest x-ray, echocardiogram, ferritin, prothrombin time, partial thromboplastin time, international normalized ratio, fibrinogen, urinalysis and cultures to assess for end-organ damage. If positive, and the patient appears ill, consider Multisystem Inflammatory Syndrome in Children (MIS-C).
  • IgA Vasculitis is usually caused by a respiratory pathogen. Keep it on your differential when assessing children who test positive for Covid-19.
  • Complications of IgA vasculitis include intussusception, heme-positive stool, microscopic hematuria, and periarticular disease.

  • Centers for Disease Control and Prevention, Health Alert Network. (2020). Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C). [online] Available at:
  • Trnka P. Henoch-Schönlein purpura in children. J Paediatr Child Health. 2013 Dec;49(12):995-1003. doi: 10.1111/jpc.12403. Epub 2013 Oct 18. PMID: 24134307.
  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health. 2005 Mar;41(3):87-93. doi: 10.1111/j.1440-1754.2005.00555.x. PMID: 15790316.


SAEM Clinical Image Series: A Young Woman with Chest Pain


A 35-year-old female with a history of intermittent palpitations who is three months post-partum presented to the emergency department (ED) with three days of sharp, substernal chest pain radiating down her left arm. She reportedly had a normal electrocardiogram (ECG) at an outside hospital on the first day of symptoms. The pain returned and was associated with one episode of vomiting the night prior to presenting to our ED. Initial ECG on arrival is shown.

Vitals: Tachycardic; afebrile; normotensive; no tachypnea or hypoxemia on room air

General: Mild distress, appears uncomfortable

Cardiovascular: Tachycardic to 100s, regular rhythm, no murmur, normal peripheral perfusion, no edema

Pulmonary: Lungs clear to auscultation, no respiratory distress

Neuro: Alert and oriented, neurologically intact

Complete blood count (CBC) and basic metabolic panel (BMP): unremarkable

Partial thromboplastin time (PTT) and international normalized ratio (INR): normal

Troponin: 42

Spontaneous coronary artery dissection (SCAD).

The patient underwent emergent coronary angiography demonstrating multivessel coronary dissection including a distal left anterior descending (LAD) hematoma with lumen compression as well as obtuse marginal (OM1) and posterior descending artery (PDA) lesions consistent with spontaneous coronary artery dissection (SCAD). She was admitted to the intensive care unit on a heparin drip, had decreasing troponin levels, and ultimately was discharged home on enalapril, metoprolol, aspirin, and clopidogrel.

SCAD is a rare but important diagnosis in the ED as it conveys serious morbidity and mortality risk. Patients present with chest pain, dyspnea, diaphoresis, and potentially signs or symptoms of heart failure from severe ischemia. Most patients are women under the age of 50, and many are pregnant, postpartum, or taking oral contraceptives. This may be mistaken for other diagnoses on presentation, such as ST-segment elevation myocardial infarction (STEMI) or takotsubo cardiomyopathy, which usually presents in post-menopausal patients, but SCAD differs in its typical patient population. Wall motion abnormalities on an echocardiogram are present, but there are not always signs of heart failure as in post-partum cardiomyopathy. Patients are often taken for urgent coronary angioplasty, though in cases with marked ischemia or hemodynamic instability, emergent coronary artery bypass graft (CABG) may be indicated. Recurrence is common; patients should be counseled on mitigating cardiovascular risk factors, particularly smoking and hypertension, and to be cautious with intense exertion and future pregnancies.

Take-Home Points

  • ECG typically shows ST elevation in the leads of the dissecting artery or arteries. Important risk factors include oral contraceptive use, being pregnant or postpartum, and fibromuscular dysplasia.
  • ED management includes aspirin, heparin, and immediate cardiology consultation, as a definitive diagnosis will be made in the cath lab.

  • Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015 Feb;5(1):37-48. doi: 10.3978/j.issn.2223-3652.2015.01.08. PMID: 25774346; PMCID: PMC4329168.
  • Macaya F, Salinas P, Gonzalo N, Fernández-Ortiz A, Macaya C, Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart. 2018 Nov 5;5(2):e000884. doi: 10.1136/openhrt-2018-000884. PMID: 30487978; PMCID: PMC6241978.


By |2021-10-26T20:58:04-07:00Nov 1, 2021|Cardiovascular, ECG, SAEM Clinical Images|
Go to Top