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Dump the Myths, Not the Milk: Medication and Imaging Considerations for Lactating Patients in the Emergency Department

lactation myths with medications and imaging
The challenges in lactation are often compounded by outdated beliefs held by clinicians.  Most of the medications we administer in the emergency department (ED) do not warrant any interruption in expression or feeding of breastmilk. Most imaging we perform in the ED is safe in the lactating patient and likewise does not need interruption. Let us convince you to trash the phrase, “Pump and Dump” in the ED.

Most medications commonly given in the ED are safe in lactation

Evidence suggests medication transfer through breast milk is frequently overestimated, with actual infant exposure typically minimal for most medications commonly prescribed in emergency settings [1]. The majority of medications administered in the ED are compatible with continued breastfeeding or pumping without interruption [2]. The practice of “pumping and dumping” is harmful to infants and lactating adults given the many benefits of lactation [3, 4]. It can cause irreparable disruptions in supply, increased parental burden and stress, and is not medically indicated except in very rare circumstances (chemotherapeutics for example) [3, 4]. When uncertainty exists regarding medication safety during lactation, clinicians should consult evidence-based resources such as LactMed or the LactRx app [iphone] to provide informed recommendations. A brief summary table is provided below for quick reference on some common medications.

Medication Class Safe in Lactation Cautions in Lactation
Analgesia
  • Acetaminophen [5]
  • Ibuprofen [6]
  • Opioids in routine doses: Oxycodone [7], Morphine [8], Hydromorphone [9],  Fentanyl [10]
  • ⚠️ Caution in very high doses or prolonged infusions of opioids
  • Data on oxycodone shows no adverse effects attributed to oxycodone in maternal doses up to 60 mg/day (~90 MME/day) [11], which is well within the range of typical short-term ED prescribing for acute pain [12]
Sedative Hypnotics
  • Propofol [13]
  • Ketamine [14]
  • Midazolam [15]
  • Safe to feed when awake
  • ⚠️ Caution in infusions and higher doses of long-acting benzodiazepines
Paralytics
  • Succinylcholine [16]
  • Rocuronium [17]
  • Safe to feed when no longer paralyzed; likely safe to feed even on infusions
Opioid Use Disorder
  • Buprenorphine [18]
  • Methadone [19]
  • Recommended to continue feeding
Antibiotics
  • Penicillins [20]
  • Cephalosporins [20]
  • Macrolides [20]
  • Metronidazole [21]
  • Doxycycline (≤21 days) [22]
  • ⚠️ Trimethoprim-sulfamethoxazole (Avoid in premature, ill or jaundiced and those with G6PD) [23]
Anti-hypertensives
  • Labetalol [24]
  • Nifedipine [25]
  • Captopril, Enalapril, Benzapril (Lisinopril—less data) [26]
  • HCTZ [27]
  • Furosemide [28]
  • ⚠️ Diuretics may decrease milk supply if dehydrated
  • ❌ ARBs (Losartan) — No safety data and other alternatives are safe [26]
Antidepressants
  • Sertraline [29]
  • Paroxetine [30]
  • Fluoxetine [31]
  • Citalopram [32]
  • Do not stop an effective antidepressant because of lactation. Risk of depression relapse outweighs the small differences in milk transfer.
  • ⚠️ Bupropion (case reports of infant seizures without causal link) [33]
  • ❌ Doxepin (case reports of infant respiratory depression, hypotonia) [34]
Anticonvulsants
  • Carbamazepine [35]
  • Valproic acid [36]
  • Phenytoin [37]
  • Lamotrigine [38]
  • ⚠️ Levetiracetam (levels can be high, monitor for somnolence) [39]
  • ⚠️ Topiramate (case reports of infant somnolence) [40]
  • ❌ Phenobarbital (Avoid due to high infant exposure and sedation risk) [41]

Most Imaging Performed in the ED is Safe in Lactation

Radiation Exposure

Radiation exposure from diagnostic imaging we typically use in the ED (CT, x-ray) is minimal and there is no need to interrupt nursing/pumping [42].

IV contrast

Iodinated and gadolinium contrast agents are safe and do not require interruption of breastfeeding [43]. Read more in the American College of Radiology 2025 ACR Manual on Contrast Media (start at page 94).

In suspected pulmonary embolism (PE), CT pulmonary angiography (CTPA) is preferred over V/Q scan in lactating patients due to contrast safety (no breastfeeding interruption required), speed and availability, and high rates of indeterminate V/Q scans requiring subsequent CTPA [43, 44].

Exception: In the rare circumstance where contrast is contraindicated (such as anaphylaxis) and a radioactive tracer is indicated (V/Q scan with Tc-99m MAA), the radioactivity does warrant separation from both patient contact and milk for a period of time determined by the rate of decay of the specific agent [45]. Keep expressed milk stored appropriately until radioactivity has been able to decay then it’s safe to feed [46].

References (AMA Format)

  1. Nauwelaerts N, Macente J, Deferm N, Bonan RH, Huang MC, Van Neste M, et al. Generic workflow to predict medicine concentrations in human milk using physiologically-based pharmacokinetic (PBPK) modelling—a contribution from the ConcePTION project. Pharmaceutics. 2023;15(5):1469. doi:10.3390/pharmaceutics15051469
  2. Premer C, Caruso K. Safety profile of the most ordered medications for breastfeeding patients in the emergency department. Am J Emerg Med. 2024;80:1-7. doi:10.1016/j.ajem.2024.02.042
  3. Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-e809. doi:10.1542/peds.2013-1985
  4. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
  5. Acetaminophen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  6. Ibuprofen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  7. Oxycodone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  8. Morphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  9. Hydromorphone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  10. Fentanyl. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  11. FDA drug label. Food and Drug Administration; 2024-2025.
  12. Zhu W, Chernew ME, Sherry TB, Maestas N. Initial opioid prescriptions among US commercially insured patients, 2012-2017. N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069
  13. Propofol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  14. Ketamine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  15. Midazolam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  16. Succinylcholine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  17. Rocuronium. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  18. Buprenorphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  19. Methadone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  20. Spencer JP, Thomas S, Trondsen Pawlowski RH. Medication safety in breastfeeding. Am Fam Physician. 2022;106(6):638-644.
  21. Metronidazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  22. Doxycycline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  23. Trimethoprim-sulfamethoxazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  24. Labetalol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  25. Nifedipine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  26. Park K. Management of women with acquired cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol. 2021.
  27. Hydrochlorothiazide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  28. Furosemide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  29. Sertraline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  30. Paroxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  31. Fluoxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  32. Citalopram. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  33. Bupropion. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  34. Doxepin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  35. Carbamazepine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  36. Valproic acid. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  37. Phenytoin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  38. Lamotrigine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  39. Levetiracetam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  40. Topiramate. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  41. Phenobarbital. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  42. Naseri M, Shahsavan M, Salahshour F, et al. Effective dose for radiological procedures in an emergency department: a cross-sectional study. Radiat Prot Dosimetry. 2020;189(1):63-68. doi:10.1093/rpd/ncaa013
  43. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media. American College of Radiology; 2025.
  44. Falster C, Hellfritzsch M, Gaist TA, et al. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol. 2023;10(11):e922-e935. doi:10.1016/S2352-3026(23)00181-3
  45. El-Sayed Y, Phillips Heine R, Wharton KR, eds. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. American College of Obstetricians and Gynecologists; 2017.
  46. Leide-Svegborn S, Ahlgren L, Johansson L, Mattsson S. Excretion of radionuclides in human breast milk after nuclear medicine examinations: biokinetic and dosimetric data and recommendations on breastfeeding interruption. Eur J Nucl Med Mol Imaging. 2016;43(5):808-821. doi:10.1007/s00259-015-3286-0
By |2026-03-24T13:23:44-07:00Mar 26, 2026|Ob/Gyn, Radiology, Tox & Medications|
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SAEM Clinical Images Series: Painful Red Eye

The patient is a 60-year-old male with a history of insulin-dependent diabetes, hypertension, and hyperlipidemia who presents to the Emergency Department after one day of sudden onset right eye pain associated with nausea and vomiting. He notes progressively blurring vision and vision loss in his right eye since the onset of the pain. His wife noted redness of his sclera and urged him to go the emergency department. He can now only sense light and shadows with his right eye. He denies traumatic injury or any history of serious ophthalmological pathology. He wears corrective eyeglasses and does not use contacts. He has no other complaints at this time.

 

Vitals: BP 149/83; HR 107; R 17; T 98.9°F; O2 sat 100 on room air.

General: Appears to be in pain and uncomfortable.

HEENT: As shown. Extraocular movements are intact. The right pupil is fixed and dilated with a relative afferent pupillary defect. There is no sign of traumatic injury.

Neck: There are no carotid bruits auscultated.

Cardiovascular: Regular rate and rhythm, no murmur.

Neurologic: Normal other than the abnormal findings of the right eye.

Imaging: POCUS of the right eye is performed, image as shown.

Acute angle-closure glaucoma.

Ultrasound shows retinal detachment with subretinal hemorrhage and associated choroidal detachment.

Acute angle-closure glaucoma occurs due to a rapid increase in intraocular pressure (IOP) due to outflow obstruction of the aqueous humor. Patients with a shallower angle between the iris and the cornea in the anterior chamber are predisposed to this condition. This is characterized clinically by severe eye pain, headache, nausea, vomiting, blurred vision, and multicolored halos around lights. If left untreated, this can result in optic neuropathy and vision loss. The diagnosis of acute angle-closure glaucoma is confirmed with elevated intraocular pressure (IOP) measurements obtained via tonometry. Normal IOPs are between 10 and 21 mmHg. The pressure in this patient’s right eye was 47 mmHg. Slit-lamp microscope exam showed a shallow anterior chamber, corneal edema, fixed dilated pupil, and conjunctival injection around the limbus (ciliary flush). Uncommonly, retinal and choroidal detachment may cause secondary acute angle-closure glaucoma, as seen in this case. Treatment includes medical and surgical interventions to reduce IOP, address underlying causes, and manage associated pain and nausea.

Take-Home Points

  • Retinal detachments are seen as a “V”-shaped hyperechoic and freely moving membrane tethered to the optic disc on ultrasound.

  • Acute angle-closure glaucoma is an ocular emergency. Delays in treatment can result in optic neuropathy and permanent vision loss.

  • Stenberg RT, Nelson J, Rabinowitz J, Simon EL. Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban. J Emerg Med. 2023;64(3):359-362. doi:10.1016/j.jemermed.2022.12.021
  • Jersey A, Perice L, Li N, Johnson J, Dulani T. Acute Angle-Closure Glaucoma Secondary to Vitreous Hemorrhage Diagnosed with the Aid of Point-of-Care Ultrasound. J Emerg Med. 2020 Dec;59(6):e235-e237. doi: 10.1016/j.jemermed.2020.08.015. Epub 2020 Sep 29. PMID: 33004244.
  • Chen SN, Ho CL, Ho JD, Guo YH, Chen TL, Chen PF. Acute angle-closure glaucoma resulting from spontaneous hemorrhagic retinal detachment in age-related macular degeneration: case reports and literature review. Jpn J Ophthalmol. 2001 May-Jun;45(3):270-5. doi: 10.1016/s0021-5155(00)00382-8. PMID: 11369377.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-03-10T21:17:06-07:00Mar 20, 2026|Ophthalmology, SAEM Clinical Images|
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Trick of Trade: Using Sterile Lubricating Gel to Manage Bloody Scalp Lacerations | A Simple Gel, a Big Fix

scalp laceration bloody gel
One of the classic scenarios encountered in the emergency department involves an elderly patient with medium to long hair who sustains a scalp laceration after a ground-level fall. They often arrive hemodynamically stable and without bony crepitus, yet the wound itself is challenging to evaluate. During transport, clotted blood frequently becomes entangled in their hair, forming a dense mat that obscures the laceration. The care team—technicians, nurses, residents, and physicians alike—may spend several minutes painstakingly separating hair and pressing on a tender scalp in an effort to expose the wound. This process is uncomfortable for the patient, time-consuming for staff, and often leaves behind residual clot. In many cases, the fallback option is to shave the matted area, which achieves exposure but results in a visible cosmetic defect.

Trick of the Trade

Applying sterile lubricating gel as a pre-irrigation adjunct [1]. It softens the clot, separates matted hair, and makes the whole process faster and gentler.

Technical Procedure · Emergency Medicine

Sterile Gel in Scalp Prep

How It Works

When a scalp laceration is obscured by clotted blood and tangled hair:

  1. Inspect for debris or foreign bodies; give a quick rinse if needed.
  2. Apply a generous amount of sterile, water-soluble lubricating gel (e.g., glycerin- or propylene-glycol–based).
  3. Wait 3-5 minutes to allow the gel to hydrate and loosen the clot, though clot dissolution is usually visible within 10-20 sec.
  4. Gently massage the area to separate hair and soften the meshwork.
  5. Irrigate or wipe with wet gauze to clear the gel. Saline or tap water both work great.
  6. Proceed with standard wound cleansing and repair once the wound is visible and clean.

In our experience with over a dozen cases at a tertiary emergency department, we found that this technique improved visualization, reduced discomfort, and required less follow-up irrigation overall—without any reported complications.

Why It’s Useful

  • Less irrigation, less hassle: Adequate wound visualization can often be achieved with less irrigation fluid.
  • Resource resilience: Especially useful in rural, wilderness medicine, or international emergency settings where any irrigant may be limited.
  • Patient comfort: Reduces painful scraping and hair pulling, with particular benefit noted in pediatric patients.
  • Safety: Sterile lubricating gels are non-cytotoxic, bacteriostatic, and easy to rinse off with whatever clean fluid you have on hand.

Important Notes

This gel trick is an adjunct, not a replacement, for wound irrigation and mechanical debridement. Avoid using this as the sole cleaning step in contaminated wounds.

Take-Home Points

Sterile lubricating gel can simplify scalp laceration prep by loosening clot and separating hair before irrigation. It is safe, inexpensive, and already available in most EDs.

References

  1. Kang JK, Shin MS, Song JK, Yun BM. Hair control during scalp surgery using a sterile gel technique. Arch Aesthetic Plast Surg. 2018;24(1):46-48. doi:10.14730/aaps.2018.24.1.46
By |2026-03-11T14:06:47-07:00Mar 18, 2026|Trauma, Tricks of the Trade|
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SAEM Clinical Images Series: Perioral Facial Swelling

The patient is a 40-year-old male with no significant past medical history who presents to the Emergency Department with perioral rash and swelling. He had been in his normal state of health the day before and woke up in the morning with an itchy rash around his mouth. He denies lip, tongue, or intraoral swelling, throat itching or sensation of throat swelling, trouble swallowing, or swelling or itching of any other part of his face. The rash has not changed locations nor has it spread beyond the perioral area. He noted a similar episode once or twice before in his life, which had improved with taking diphenhydramine. He denies the presence of a rash or itching on any other part of his body, wheezing, shortness of breath, GI symptoms, or dizziness. He denies any exposure to new foods or medications, and he has not been exposed to ACE inhibitors nor ARBs. He has no other complaints at this time.

 

Vitals: BP 141/97; HR 88; R 19; T 98.2°F; O2 sat 98% on room air.

General: Awake and alert, no distress, speaking in a clear voice.

HEENT: As shown in the images provided. There is no oropharyngeal swelling. There is no stridor.

Respiratory: Clear to auscultation, no wheezes.

Skin: There is no rash or swelling elsewhere on the patient’s body.

Non-contributory

The patient has been dyeing his facial hair.

Para-phenylenediamine.

Upon further questioning, the patient admitted to applying an “instant hair dye shampoo” to his facial hair the day before presentation. Review of the product ingredients revealed para-phenylenediamine. He later recalled that his previous episodes of peri-oral swelling had occurred after exposure to the same product. Para-phenylenediamine can be found in commercial black and dark brown hair dyes, as well as in henna tattoos. Reactions can range from local erythema and contact dermatitis to bullous dermatitis and significant edema in severely affected patients. Symptoms may appear similar to angioedema and may only be distinguished after careful history identifies hair dye or henna exposure. Initial management is to remove the offending dye or henna with thorough washing. Topical steroids or a short course of oral steroids can be used for severe symptoms. Prevention of exposures in sensitized individuals remains the most important tenet of care. Hair dyes recommend consumers test the dye on a small patch of skin prior to using it, which has been proven to help identify those who will develop a reaction.

Take-Home Points

  • Para-phenylenediamine is a compound found in henna and hair dye that is commonly responsible for adverse skin reactions, but may be under recognized when used for facial hair.

  • Allergic contact dermatitis from this compound may show a range of clinical skin findings and sometimes may mimic angioedema.

  • Mukkanna KS, Stone NM, Ingram JR. Para-phenylenediamine allergy: current perspectives on diagnosis and management. J Asthma Allergy. 2017 Jan 18;10:9-15. doi: 10.2147/JAA.S90265. PMID: 28176912; PMCID: PMC5261844.
  • Krasteva M, Cristaudo A, Hall B, Orton D, Rudzki E, Santucci B, Toutain H, Wilkinson J. Contact sensitivity to hair dyes can be detected by the consumer open test. Eur J Dermatol. 2002 Jul-Aug;12(4):322-6. PMID: 12095875.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-03-10T21:10:56-07:00Mar 16, 2026|Allergy-Immunology, SAEM Clinical Images, Tox & Medications|
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ALiEM AIR Series | Endocrine Module (2025)

ALiEM AIR Certified seal and Endocrine 2025 module shield badge

Welcome to the AIR ENDOCRINE Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to endocrine emergencies in the Emergency Department. 11 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 6 AIR and 5 Honorable Mentions. We recommend programs give 5.5 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Want asynchronous Individualized Interactive Instruction (III) credit?
Take the AIR quiz at ALiEMU. Free, 1-time login required.

Take the Endocrine Module →

Highlighted Quality Posts: Endocrine 2025

Site Article Author Date Label
EMCrit Hyperosmolar hyperglycemic state (HHS) Dr. Josh Farkas June 1, 2024

AIR
EMCrit Hypokalemia Dr. Josh Farkas July 4, 2024 AIR
EMCrit Hyperkalemia Dr. Josh Farkas November 5, 2024 AIR
EMCrit Hyperkalemia Dr. Josh Farkas July 4, 2024 AIR
EMCrit Hyponatremia Dr. Josh Farkas July 4, 2024 AIR
EM Ottawa These are the Roids you are looking for – Steroids in the Ed Dr. Naman Arora January 9, 2025 AIR
EMCrit

Hypernatremia and dehydration in the ICU

 Dr. Josh Farkas July 5, 2024 AIR
Rebel EM Hyperkalemia Dr. Anand Swaminathan June 26, 2024 HR
EM Docs Alcohol Withdrawal Dr. Kyler Osborne December 18, 2024 HR
St Emlyns Blog GLP-1A tocxicity: What do emergency clinicians need to know about drugs like ozempic and wegovy? Dr. Gregory Yates November 24, 2024 HR
UMEM Pearls Euglycemic DKA Pitfalls and Pearls Dr. Cody Couperus August 20, 2024 HR

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

By |2026-04-29T12:02:14-07:00Mar 15, 2026|Approved Instructional Resources (AIR series), Endocrine-Metabolic|
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SAEM Clinical Images Series: Green Foot

The patient is a 59-year-old male with a history of prior DVT, atrial fibrillation, HTN, alcohol use and COPD who presents to the Emergency Department with chest pain, dyspnea, and left lower extremity swelling and pain. He had a prior hospital admission two weeks ago for leg swelling and cellulitis. He was previously prescribed oral gentamicin and topical mupirocin for concerns of foot infection, which he has been compliant with taking. He has been working long hours as a construction worker, but knows of no chemical exposure to his feet and denies walking barefoot. He has had no fever and denies any other complaints at this time.

 

Vitals: BP 151/69; HR 93; R 18; T 97.7°F; O2 sat 95% room air.

General: No acute distress.

Respiratory: Mild wheezes bilaterally.

Extremities: Mild bilateral lower extremity swelling, worse on left compared to right. Left foot discolored as shown in the image – when asked, the patient states the discoloration started initially on the great toenail and progressed to the sole of the foot.

CBC: WBC: 10.2; Hgb: 12.7

Na: 130

ESR: 6

CRP: 0.8

CXR: Mild pulmonary edema.

Foot X-ray: No acute findings, old Lisfranc injury.

Ultrasound: Negative for DVT.

The patient has Green Foot Syndrome.

Pseudomonas aeruginosa

Green foot syndrome is a rarely diagnosed Pseudomonas aeruginosa infection secondary to chronic skin moisture of the feet, identified from the greenish discoloration of skin. The green discoloration is due to pyocyanin and pyoverdine, giving the skin a bluish-green color. Symptoms can also include pruritus, pain, malodor, and paresthesias. Our patient was admitted to the hospital with dermatology consultation, who recommended vinegar soaks, gentamicin cream, and 0.3% ciprofloxacin solution. Other case studies have reported successful treatment by removing the inciting agent and keeping skin dry, acidic soaks such as benzoyl peroxide, and/or oral fluoroquinolones. Green foot syndrome has been reported in soldiers wearing combat boots for long hours and in patients during prolonged cast use. The moist environment of damp skin in boots provides an ideal environment for P. aeruginosa to grow. Our patient often wore construction boots with 2 pairs of socks for long hours at work, which made him susceptible to this infection.

Take-Home Points

  • When patients present with lower extremity complaints, always carefully assess the feet; this patient’s initial complaint was not skin discoloration.

  • Pseudomonas aeruginosa infections can cause a greenish discoloration to feet chronically kept in moist conditions, such as frequent and extended shoe or cast use.

  • García-Martínez FJ, López-Martín I, Castellanos-González M, Segurado-Rodríguez MA. Green foot ulcers. Enferm Infecc Microbiol Clin. 2017 Oct;35(8):536-537. English, Spanish. doi: 10.1016/j.eimc.2015.10.010. Epub 2015 Nov 26. PMID: 26627144.
  • Spernovasilis N, Psichogiou M, Poulakou G. Skin manifestations of Pseudomonas aeruginosa infections. Curr Opin Infect Dis. 2021 Apr 1;34(2):72-79. doi: 10.1097/QCO.0000000000000717. PMID: 33492004.
  • Wu DC, Chan WW, Metelitsa AI, Fiorillo L, Lin AN. Pseudomonas skin infection: clinical features, epidemiology, and management. Am J Clin Dermatol. 2011 Jun 1;12(3):157-69. doi: 10.2165/11539770-000000000-00000. PMID: 21469761.
  • Sloan B, Meffert JJ. “Boot foot” with pseudomonas colonization. J Am Acad Dermatol. 2005;52(6):1109-1110. doi:10.1016/j.jaad.2005.01.105
  • Park, Y., & Bae, J. (2013). Green foot syndrome: A case series of 14 patients from an armed forces hospital. Journal of the American Academy of Dermatology, 69(4), e198-e199. https://doi.org/10.1016/j.jaad.2013.05.012
  • Lee SH, Cho SB. Cast-related green foot syndrome. Clin Exp Dermatol. 2009;34(7):2008-2009. doi:10.1111/j.1365-2230.2009.03317.x
  • Macgregor DM. An unusual presentation of immersion foot. Br J Sports Med. 2004 Aug;38(4):E11. doi: 10.1136/bjsm.2003.007385. PMID: 15273204; PMCID: PMC1724852.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-03-04T10:25:32-08:00Mar 13, 2026|Infectious Disease, SAEM Clinical Images|
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