Shock Syndromes II
Mortality prediction increases sharply with each additional point, starting at 3% for 0 or 1 point and
reaching 90% for 5 or more points. SCORTEN mortality estimates are often used as benchmark
rates to assess noncontrolled pharmacotherapy studies.
Identification, discontinuation, and avoidance of likely or suspected causes are imperative. Causative
agents with a long half-life should be identified and strategies to expedite removal considered.
Overt assessment of mucous membranes to prevent extension of injury and related sequelae. This
includes the respiratory tract, eyes, and GI tract.
Cornerstones of managing SJS and TEN are:
Resuscitation and supportive care (recent supportive care guidelines are outlined in J Am Acad
Dermatol. 2020;82:1553-1567).
Goal-directed fluid resuscitation should be initiated immediately to maintain:
| (a) | MAP above 65 mm Hg |
|---|---|
| (b) | Central venous pressure 8 to 12 mm Hg |
| (c) | Urine output 0.5 to 1 mL/kg/h |
| (d) | Central venous oxygen saturation above 70% |
ii.
Respiratory function should be supported with respiratory therapy and continual assessment for
intubation, as appropriate.
iii.
Avoid using skin to anchor devices and catheters.
iv.
Physical and occupational therapy, when appropriate
Limit debridement of necrotic epidermis. Best practice recommendations support leaving detached
epidermis in place as a biologic dressing together with coverage of affected areas with an artificial
or biologic dressing. This may be done serially because progression of affected areas may occur.
Topical emollients (eg, petroleum jelly) should be applied to the entire epidermis.
Management of extracutaneous injuries
Ocular involvement
| (a) | Adequate ocular lubrication |
|---|---|
| (b) | Consideration of topical, preservative-free ophthalmic corticosteroid drops |
| (c) | Treatment of corneal fluorescein or ulceration |
ii.
Oral involvement
| (a) | Maintain lip barrier integrity (eg, white paraffin). |
|---|---|
| (b) | Consider antiseptic oral rinse (eg, chlorhexidine). |
| (c) | Consider topical corticosteroid rinse (eg, betamethasone). |
| d. | Nutrition support (see Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support chapter) |
Avoidance and treatment of infectious complications
Implement infection prevention best practices, including minimizing unnecessary devices and
procedures related to health care–associated infection.
ii.
Prophylactic antibiotic therapy is not recommended for SJS and TEN.
iii.
Empiric antibiotic therapy should be carefully chosen and reserved for suspected infections, as
evidenced by signs and symptoms of sepsis or site-specific infection. Continuation of antibiotic
therapy should be reserved for confirmed infection, and duration should be limited according
to the specific infection.
Adjuvant therapies
Plasmapheresis—Support is derived from case series; thought to be a generally safe and effective
strategy to remove pathogenic, nondialyzable plasma factors, including some drugs, toxins,
metabolites, antibodies, immune complexes, and disease-inducing cytokines