Malcolm Greaves

Angioedema in the Emergency Department

Angioedema is defined as the occurrence of one or more acute short-lived (almost invariably less than 72 h duration) erythematous or skin-coloured skin and/or mucosal non-pitting swellings. It is due to sudden onset of localized increase in vasopermeability affecting the deep mucosal or cutaneous dermis and submucosal or subcutaneous tissue. Pain may occur; itch is common in those cases associated with urticaria but frequently the swellings are asymptomatic. They subside without staining or desquamation of the skin or mucosae. Scratching or rubbing may cause bruising. The patient presenting in the Accident and Emergency department with a tentative diagnosis of angioedema must be subjected to careful history-taking (from the patient if possible, or alternatively from any first-hand witnesses) and meticulous clinical examinations. There is a long list of causes of swellings – mainly on the face – which can mimic angioedema. The more important are listed in Table 1. Angioedema, especially when it affects the upper respiratory or gastrointestinal tract is a common and highly alarming occurrence for patient, his or her family and friends and Emergency Room staff alike. This is because of the sudden onset of swelling, the angor animi and sense of impending doom due to feared or actual onset of asphyxia often experienced by the patient, and involvement of skin and mucocutaneous junctions bringing about a grotesque appearance. Not uncommonly the tongue becomes too big for the mouth and protrudes and speech may be impossible. Intestinal angioedema, which frequently mimics an acute abdomen with or without accompanying shock is also a challenging event for all concerned. Angioedema with any of these presentations can be due to a variety of causes, with important implications for treatment. Although elements of emergency treat-