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To some, emergency medicine and dermatology may seem to be two of the most unrelated specialties in medicine, and in our daily practice dermatologic complaints most likely respresent a small percentage of our 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. This chapter reviews those special situations and discusses common and uncommon dermatologic complaints.
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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.
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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, medical and surgical history, last meal, and events leading up to the presentation may provide information necessary to begin appropriate management.
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Angioedema and Urticaria
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Essentials of Diagnosis
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- Swelling of face, lips, tongue
- May lead to airway compromise
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General Considerations
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Angioedema forms in the deeper dermal and subcutaneous tissues of the distal extremities, tongue, lips, mouth, face, and neck. Particularly dangerous is the involvement of the mouth, tongue, and lower airway, which can lead to severe airway compromise. Angioedema is believed to be a similar to urticaria, which is present in half of the cases, but a deeper reaction. 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 16 years of age. The acquired form is most commonly secondary to angiotensin-converting enzyme (ACE) inhibitors 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.
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Emergency airway protection is mandated if airway compromise is impending or present. Treat shock if present. Discontinue any implicated medications or substances. Supply oxygen to maintain oxygen saturation at greater than 90%. In severe angioedema with airway compromise, administer epinephrine 0.1–0.5 mg (1:1000 solution) subcutaneously or preferably ...