Hives

 


A common presenting complaint, do not simply pass off these individuals as a hypersensitivity reaction or benign condition without ruling out the multiple causes of hives precipitation.  It’s best to isolate them into 5 broad categories…

Infectious

Environmental

Physical

Malignant

Autoimmune
Pharyngitis Heat/cold exposure Pregnancy (PUPPP) Lymphoma Rheumatoid arthritis
URI/GI/GU infx Food allergies Stress Leukemia SLE
Fungal/parasitic infx Dust, molds, pollens, danders Exercise Other carcinoma Polymyositis
Virus (coxsackie, hepatitis, EBV, etc) Sulfites, tartrazine, benzoates

Vasculitides
Mycoplasma Water exposure

Amyloidosis
Syphillis Sun exposure

Sarcoidosis
Malaria


Hyperthyroid

 

  • Workup
    • Physical exam
      • HEENT: pharyngitis? thyroid dz? Lymphadenopathy
      • CV/Resp: URI? axial lymph nodes
      • Abd: Signs of liver dz?
      • Skin: Signs of autoimmune dz, check feet for fungemia
    • Definition of a “Hive”
      • Well-circumscribed, raised, blanching lesion w/ erythematous borders and central pallor
      • Linear, circular, or serpiginous; tend to be migratory and transient
  • Labs
    • If acute, not needed
    • If chronic (>1wk), consider CBC, CMP, ESR, CRP, CXR
      • Eosinophilia? Leukocytosis? LFT elevation? Inflammation?
  • Treatment
  1. Antihistamines
    1. First-line, should be initial treatment of choice
      1. Hydroxyzine, Benadryl, brompheniramine, loratadine, fexofenadine, certrazine
    2. For cold urticaria, cyproheptadine (2-4mg bit/tid) might be best
    3. For cholinergic urticaria (exercise/stress/heat) , hydroxyzine might be best
  2. Steroids
    1. Second-line, employ only if antihistamines fail

Eclampsia

 

 

  1. These are rare but truly emergent conditions of both pre- and post-partum women, with documented cases of both found up to 6 weeks postpartum!
  1. Pregnant pt >20wks is pre-eclamptic if…
  1. +HTN (>140/90)
  2. Proteinuria (>300mg/24h)
  1. You won’t diagnose this in the ED, but a dip w/ large protein is indicative
  1. If <20wks with HTN and proteinuria likely has a molar pregnancy
  2. 16% of pts w/ eclampsia may not have HTN, 38% might not have proteinuria!
  1. Mattar, F, Sibai BM. Eclampsia. VIII. Risk Factors for maternal morbidity. Am J Ob Gyn. 1990;163:1049-55.
  2. Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ. Nov 26 1994;309(6966):1395-400
  1. Pre-eclampsia + seizure = eclampsia
  1. Seizure not secondary to…
  1. Pre-existing epilepsy, electrolyte disturbances, intracranial pathology, trauma

About the Seizure

  1. 80% of seizures occur intrapartum or w/in 48h postpartum
  2. Seizure is classically tonic-clonic and triphasic…
  1. Phase 1:  15-20sec, begins w/ facial twitching, body becomes rigid, leading to generalized muscular contractions
  2. Phase 2:  ~60 sec, starting in the jaw, moves to the muscles of the face and eyelids, and then spreads throughout the body
  1. Typically there is a cessation of breathing during this phase
  1. Phase 3:  Coma or post-ictal state with hopeful recovery to confused or normal state, but patient will have no recollection of even
  1. May have hyperventilation to compensate for previous breath-holding

 

Pathogenesis

  1. Eclamptic pts have insufficient uteroplacental arterial development and there is an imbalance in vascular growth factors
  2. Endothelial dysfunction is prominent in the brain and kidneys and increased leptin levels increase oxidative stress and neutrophil invasion into blood vessels and subsequent destruction
  3. Decreased cerebral blood flow due to HTN, along with increased vascular permeability subsequently leads to cerebral edema and encephalopathy

 

Clinical Features

  1. Headache (80%, usually frontal)
  2. Generalized edema (50%)
  3. Visual disturbances (30-40%, usually photophobia or blurred vision)

 

 

WORKUP

DIFFERENTIAL

POC Tests:  dexi, pulse ox, udip

Adrenal insufficiency/crisis

 

Intracranial pathology (stroke, tumor…)

Labs: CBC+smear, DIC panel (coags, fibrin split products, haptoglobin, LDH), CMP, lactate, protein/Cr ratio (urine) helps the floor

Sepsis

 

Hypoglycemia

Imaging: CT Head (not routine, but 50% of women imaged show abnormalities)

Drugs/EtOH (or withdrawal)

Diagnostics: Continuous fetal monitoring

Metabolic derangement

 

Management:

  1. IV, O2, monitor, advanced airway equipment to the bedside
  2. Activate OB early (delivery is the only cure)
  3. Move pt to left lateral decubitus position and pad gurney
  4. Medications…
  1. Sz first line:  Mag sulfate (load 6mg over 20min, then 2g/h gtt)
  1. If seizing after initial bolus, additional 2g bolus can be given
  2. Monitor DTRs for signs of toxicity and consider Ca if decreased
  3. 85% of seizure activity responds to Mag alone
  1. Sz second line:  BZDs or phenytoin
  2. HTN: Hydralazine (5-10mg) or labetalol (20-40mg q15min prn)
  1. Ensure sBP>90 (will cause placental insufficiency)
  1. If <32wks gestation: betamethasone (12 mg IM q24h × 2 doses) or dexamethasone (6 mg IM q12h × 4 doses) for fetal lung development