What are key assessment findings on day 2 of staphylococcal scalded skin syndrome in a 2-year-old?

Day 2 Assessment of Staphylococcal Scalded Skin Syndrome in a 2-Year-Old

On day 2 of SSSS, focus your assessment on progression of skin involvement, signs of systemic toxicity, fluid/electrolyte derangements, and secondary complications, as the disease typically peaks within 24-48 hours of onset. 1, 2

Critical Vital Signs and Systemic Assessment

• Temperature monitoring for persistent or worsening fever, which indicates ongoing toxin production or secondary infection 1, 3
• Heart rate and blood pressure to detect early sepsis or hypovolemia from extensive skin loss 3
• Oxygen saturation to identify respiratory compromise 1
• Urine output monitoring (should be >1 mL/kg/hr) to assess adequate fluid resuscitation and renal perfusion 3
• Mental status changes including confusion or lethargy, which may indicate sepsis or electrolyte abnormalities 1, 3

Skin Examination Specifics

• Document percentage of body surface area (BSA) involved using a Lund-Browder chart or body map to track progression or improvement 1
• Assess for new bullae formation or extension of existing lesions, particularly in friction zones (axillae, groin, neck) 2, 4
• Evaluate Nikolsky sign (lateral pressure causing skin sloughing) in perilesional areas to gauge disease activity 2
• Examine for areas of denuded dermis that are weeping, bleeding, or showing signs of secondary bacterial colonization 1, 5
• Assess skin pain level, as increasing pain may indicate secondary infection rather than improvement 1
• Look for periorificial crusting around eyes, nose, and mouth, which is characteristic of SSSS 2

Mucous Membrane Examination

• Confirm absence of mucosal involvement (oral, ocular, genital) to distinguish SSSS from toxic epidermal necrolysis, which requires different management 6, 1
• Check conjunctivae for inflammation without erosions (mild conjunctivitis may occur, but true mucosal erosions suggest TEN) 6

Laboratory Monitoring

• Complete blood count to assess for leukopenia (a frequent finding in severe SSSS) or leukocytosis suggesting secondary infection 3
• C-reactive protein to monitor inflammatory response and detect worsening infection 1, 3
• Serum sodium as hyponatremia is a common complication from fluid shifts and losses 3
• Renal function (BUN/creatinine) to detect acute kidney injury from hypovolemia 1, 3
• Liver function tests, glucose, magnesium, and phosphate as baseline and to guide supportive care 1

Fluid Balance Assessment

• Monitor for fluid overload, which is paradoxically more common than hypovolemia despite extensive skin loss 3
• Watch for signs of overhydration including peripheral edema, pulmonary crackles, or increasing oxygen requirements 3
• Calculate fluid balance (intake minus output) over the previous 24 hours 3
• Assess for dehydration signs including decreased skin turgor in unaffected areas, dry mucous membranes, and sunken fontanelle if still open 3, 4

Signs of Secondary Infection or Sepsis

• Increasing skin pain in denuded areas 1
• Purulent drainage from skin lesions 1
• Rising C-reactive protein or new-onset neutrophilia 1
• Hypotension or persistent tachycardia despite adequate fluid resuscitation 1
• Reduced oxygen saturation or increased work of breathing 1

Response to Antibiotic Therapy

• Evaluate for clinical improvement including cessation of new blister formation, which should occur within 24-48 hours of appropriate antibiotics 2, 7
• If no improvement after 24-48 hours on beta-lactam therapy, consider MRSA coverage with vancomycin or linezolid 8, 2, 7
• Review culture results from initial blood, skin lesions, and potential primary infection sites (nasopharynx, conjunctivae, umbilicus) to guide antibiotic adjustment 1, 2

Wound Care Assessment

• Examine dressing integrity and assess whether bland emollients and appropriate wound coverage are maintaining moisture balance 1, 5
• Check for adherent dressings causing trauma during changes 5
• Evaluate pain control adequacy during dressing changes and at rest 5

Common Pitfalls to Avoid

• Do not mistake fluid overload for inadequate resuscitation—SSSS patients frequently develop edema despite appropriate fluid management 3
• Do not assume improvement based solely on defervescence—assess skin progression and systemic markers 2
• Do not delay MRSA coverage in critically ill patients or those in high-prevalence communities 8, 2, 7
• Do not overlook hyponatremia and leukopenia, which are frequent laboratory findings requiring monitoring 3