A 42-year-old woman with toxic epidermal necrolysis covering approximately 65% of her total body surface area, transferred from an outside hospital after receiving Parkland-formula fluid resuscitation and is now grossly volume-overloaded with pulmonary edema, hypotension, and worsening skin detachment.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Recognition of the Resuscitation Misstep
Decongestion and Mucosal Protection
Electrolyte Surveillance and Glycemic Control
Withdrawal of Offending Agent and Definitive Disposition
High-Yield Clinical Pearls
Toxic epidermal necrolysis is a drug reaction, not a thermal injury; fluid resuscitation must NOT follow the Parkland formula. Capillary leak in TEN is limited to the epidermis and dermis, not the deep interstitium.
TEN fluid goal is urine output 0.5 mL/kg/hr (versus 0.5–1 mL/kg/hr in burns) with maintenance crystalloid plus insensible loss replacement (~1.5–2 mL/kg/24h).
Allopurinol is a prototypical high-risk drug for severe cutaneous adverse reactions (SCARs), particularly in HLA-B*5801-positive patients. Latency is typically 7–21 days.
Ocular involvement requires urgent ophthalmology evaluation within 24 hours to prevent symblepharon, corneal ulceration, and permanent blindness.
Early enteral nutrition (within 24–48 hours) reduces mortality, infection, and length of stay; TPN is associated with worse outcomes.
Cyclosporine 3 mg/kg/day has the strongest evidence base among immunomodulators for halting TEN progression and reducing mortality when started early.
Systemic corticosteroids as monotherapy are not recommended and may increase sepsis-related mortality.
Admission to a TEN-capable unit (burn center with SCAR experience) reduces mortality from >50% to <30%.
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