Chapter 48: Dermatologic Emergencies

IMMEDIATE RECOGNITION AND MANAGEMENT OF LIFE-THREATENING PROBLEMS

To some, emergency medicine and dermatology may seem to be two of the most unrelated specialties in medicine. In daily practice, dermatologic complaints typically represent a small percentage of the normal daily census, but the emergency physician will encounter many patients presenting with dermatologic complaints. The astute clinician will realize that, although rare, some of these problems can be life threatening. Some patients may even require emergency airway protection and vigorous resuscitation; certain cases may even require transfer to a specialized facility (ie, burn center). This chapter reviews those special situations and discusses common and uncommon dermatologic complaints.

Initial Evaluation

The initial evaluation begins with the primary survey and vital signs. Always focus special attention on airway, breathing, and circulation (the ABCs). Note any abnormal vital signs and oxygen saturation, and be alert to subtle changes in mental status or behavior that may indicate impending airway or cardiovascular collapse. The ABCs apply to all clinical situations, and a thorough history and examination are often the most helpful tools in arriving at any diagnosis. The dermatologic examination must be performed on a disrobed patient. Inspect all areas of the skin and mucosal surfaces before addressing specific lesions. Providers and staff must consider and use appropriate personal protective equipment (PPE) when interacting with the patient.

History

Parallel to the assessment of the ABCs is a thorough history that includes potential recent exposures to foods, medications, plants, insects, and the like that may have triggered the condition. An ample history, addressing the patient’s allergies, medications, prior medical and surgical history, last meal, and events leading up to the presentation may provide information necessary to begin appropriate management.

ANGIOEDEMA AND URTICARIA

1. Angioedema

General Considerations

Angioedema is swelling in the deeper dermal and subcutaneous tissues of the distal extremities, tongue, lips, mouth, face, and neck and bowel. Particularly dangerous is the involvement of the mouth, tongue, and lower airway, which can lead to airway compromise. Angioedema is believed to be similar to urticaria, but a deeper reaction and a skin rash may not be present. Two subtypes exist, the rare hereditary form and the acquired form. The autosomal dominant hereditary variant is usually due to C1-esterase deficiency or defect with 75% of patients with hereditary angioedema (HAE) having their first episode before age 16. The acquired form is most commonly secondary to angiotensin-converting enzyme (ACE) inhibitors or nonsteroidal anti-inflammatory drugs (NSAIDs) and has increased in prevalence because of widespread usage of these drugs. Patients who have been using ACE inhibitors for months or years can still develop angioedema from these agents.