Authors: Lucy Ellis, Emma Tilley, Alex Owen / Editor: Nick Tilbury / Codes: DC4, DP2, RP7, SLO3 / Published: 04/08/2020

A 67-year-old man with a history of psoriasis presents with a 3-day history of malaise, oliguria and a widespread, pruritic, erythematous rash which had started on his legs before spreading to his torso and arms. He had recently been started on acitretin for his psoriasis and he reported a high weekly alcohol intake. He was pre-alerted as the paramedics had been unable to obtain a radial pulse and he was hypothermic. 

On initial A-E assessment in resus the patient looks unwell and is shivering uncontrollably.

A- Patent
B- RR 24, oxygen saturations 94% on air. Chest clear
C- BP 70/40 HR 120 (AF). CRT 5 seconds. Anuric.
D- GCS 15 BM 6
E- Temperature 33.1. Widespread erythematous rash with localised areas of desquamation on his soles and palms. Mucous membranes intact.


VBG: Metabolic acidosis pH 7.26. Lactate 7

U+E: EGFR 14 (baseline >90)

CRP 240

He does not respond to initial management in ED and is referred to ITU for inotropic support.