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Edema, Emergency Medicine

Basics

Description

- Clinically apparent accumulation of extravascular fluid due to a derangement in the balance of oncotic and hydrostatic forces: - Increase in venous/capillary hydrostatic pressure - Decrease in plasma oncotic pressure - Increase in interstitial oncotic pressure - Increase in capillary permeability - Increase in lymphatic pressure due to obstruction - Combination of these factors

- Generalized edema (anasarca): - Edema is most prominent in dependent areas: - Feet - Sacrum - Bilateral lower extremities - Face/periorbital (especially in the morning)

- Myxedema: - Pretibial nonpitting edema - Dry waxy swelling of skin and SC tissues - Periorbital most common (puffy eyes) - Nondependent areas - Fatigue - Cold intolerance - Weight gain - Constipation - Slowed deep-tendon reflex relaxation

- Localized: - Chronic venous insufficiency: - Chronic pitting - Skin discoloration (hemosiderin deposits) - Dermatitis/ulceration - Varicose veins

- Infectious/inflammatory: - Chills - Fever - Erythema - Increased warmth

- Allergic: - Pruritus - Hives - Involvement of the lips and the oral mucosa

- Hepatic etiology suspected: - Serum albumin - Liver function tests - Prothrombin time and partial thromboplastin time

  • Clinically apparent accumulation of extravascular fluid due to a derangement in the balance of oncotic and hydrostatic forces:Increase in venous/capillary hydrostatic pressureDecrease in plasma oncotic pressureIncrease in interstitial oncotic pressureIncrease in capillary permeabilityIncrease in lymphatic pressure due to obstructionCombination of these factors
  • Generalized, as with CHF or nephrotic syndrome
  • Localized, as with deep vein thrombosis
  • Increased venous hydrostatic pressure or decreased oncotic pressure results in pitting edema
  • Protein-rich extravasated fluid results in nonpitting edema
  • In certain disorders, there is no clear relation to Starling forces:Idiopathic (cyclic) edema:Worsened with heatMore common in womenNot necessarily related to menses

Etiology

  • Generalized:Heart failureCor pulmonaleCardiomyopathiesConstrictive pericarditisPulmonary HTN:Acute glomerulonephritisRenal failureMedication related (often secondary to salt retention):Steroids/estrogens/progestinsNSAIDsAntihypertensives (especially vasodilators)LithiumCyclosporineInsulinThiazolidinediones (glitazones)Growth hormoneInterleukin-2MAOIsPramipexoleDocetaxelMinoxidilAcute withdrawal of diureticsIdiopathic (cyclic) edemaMyxedemaCirrhosisNephrotic syndromeProtein-losing enteropathy/malabsorptionStarvationPregnancy
  • Localized:Deep vein thrombosisVenous insufficiencyThrombophlebitisChronic lymphangitisCellulitisBaker cystVasculitisAngioedema:Hypothyroidism (myxedema)Mechanical traumaThermal injuriesRadiation injuriesChemical burnsHemiplegiaReflex sympathetic dystrophyCompressive or invasive tumorPostsurgical resection of lymphaticsPostirradiationFilariasis

Diagnosis

Signs and Symptoms

  • Weight gain of several kilograms
  • Discomfort in the affected areas
  • Swelling
  • Tenderness
  • Pitting edema:Increased venous hydrostatic pressure or decreased oncotic pressure
  • Nonpitting edema:Protein-rich extravasated fluid
  • Generalized edema (anasarca):Edema is most prominent in dependent areas:FeetSacrumBilateral lower extremitiesFace/periorbital (especially in the morning)Cardiac:DyspneaOrthopneaParoxysmal nocturnal dyspneaIncreased jugular venous pressureRalesS3 gallopRenal:AnorexiaPuffy eyelidsFrothy urineOliguriaDark urineHematuriaHTNHepatic:JaundiceSpider angiomasPalmar erythemaGynecomastiaTesticular atrophyAscitesMyxedema:Pretibial nonpitting edemaDry waxy swelling of skin and SC tissuesPeriorbital most common (puffy eyes)Nondependent areasFatigueCold intoleranceWeight gainConstipationSlowed deep-tendon reflex relaxationIdiopathic:
  • Localized:Chronic venous insufficiency:Chronic pittingSkin discoloration (hemosiderin deposits)Dermatitis/ulcerationVaricose veinsHistory of trauma:Mechanical, thermal, radiationInfectious/inflammatory:ChillsFeverErythemaIncreased warmthAllergic:PruritusHivesInvolvement of the lips and the oral mucosa
  • Common secondary to hormonally mediated fluid retention
  • When involving hands and face, may be early sign of preeclampsia
  • Dependent edema:Usually in late pregnancyFrom impedance of venous return
  • Diuretics contraindicated

Essential Workup

Diagnostic studies should be directed by the underlying etiology suggested by the history and physical exam. á

Diagnosis Tests & Interpretation

Lab

  • Cardiac etiology suspected:
  • Deep vein thrombosis suspected:d-dimer (for patients with low clinical probability to rule out DVT)
  • Renal etiology suspected:ElectrolytesBUN and creatinineUrinalysisUrine electrolytes and proteinSerum lipids
  • Hepatic etiology suspected:Serum albuminLiver function testsProthrombin time and partial thromboplastin time
  • Myxedema suspected:

Imaging

  • Cardiac etiology suspected:
  • Localized edema to an extremity:US (duplex scanning) or contrast venography
  • High suspicion for abdominal or pelvic malignancy:

Differential Diagnosis

  • Cellulitis
  • Contact dermatitis
  • Diffuse SC infiltrative process
  • Lymphedema
  • Obesity

Treatment

Initial Stabilization/Therapy

See "ED Treatment."Ł á

Ed Treatment/Procedures

  • Treatment should be directed toward the underlying cause.
  • Diuretics are usually indicated in cases of generalized edema but are not required emergently.
  • Diuretics may be deleterious in patients with cirrhosis and ascites, as rapid fluid shifts may precipitate hepatorenal syndrome.

Medication

  • Amiloride: 5-10 mg PO daily
  • Captopril: 6.25-100 mg PO TID (max. 450 mg/d)
  • Furosemide: 20-80 mg IV/PO QID (max. 600 mg/d)
  • Hydrochlorothiazide: 25-100 mg PO BID
  • Spironolactone: 25-200 mg PO BID

Follow-Up

Disposition

Admission Criteria

  • Base the decision to admit the patient on the underlying etiology.
  • Concomitant cardiovascular or pulmonary compromise
  • Inability to ambulate without adequate home support
  • Hypoxia

Discharge Criteria

  • Patient should be advised to decrease salt intake.
  • Elastic support stockings
  • Elevation of involved limbs

Issues for Referral

  • Patients >45 yr with chronic edema, or whose symptoms suggest a cardiopulmonary etiology require follow-up EKG.
  • Patients with pulmonary HTN of unknown cause should be referred for a sleep study to evaluate for sleep apnea.
  • A negative US in a patient at high risk for DVT requires urgent repeat study in 5-7 days.

Followup Recommendations

Patients with chronic edema may follow-up with primary care doctor for continued workup and treatment. á

Pearls and Pitfalls

  • Classify edema as generalized vs. localized, pitting vs. nonpitting.
  • Pitting edema is caused by "protein-poor"Ł extravasated fluid (by increased hydrostatic pressure or decreased oncotic pressure).
  • Nonpitting edema is caused by "protein-rich"Ł extravasated fluids (lymphedema or increased capillary permeability).
  • Generalized or bilateral leg edema necessitates workup of systemic disease.
  • Acute unilateral leg edema requires evaluation for DVT.
  • Consider preeclampsia in pregnant patients.

Additional Reading

  • Braunwald áE, Loscalzo áJ. Edema. In: Longo áDL, Fauci áAS, Kasper áDL, et al., eds. Harrisons Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012.
  • Ely áJW, Osheroff áJA, Chambliss áML, et al. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006;19:148-160.
  • Mockler áJ, Neher áJO, St Anna áL, et al. Clinical inquiries. What is the differential diagnosis of chronic leg edema in primary care? J Fam Pract. 2008;57:188-189.
  • O'Brien áJG, Chennubhotla áSA, Chennubhotla áRV. Treatment of edema. Am Fam Physician. 2005;71:2111-2117.
  • Stern áSC, Cifu áAS, Altkorn áD. I Have a patient with edema. How do I determine the cause? In: Stern áSC, Cifu áAS, Altkorn áD, eds. Symptom to Diagnosis: An Evidence-based Guide. 2nd ed. New York, NY: McGraw-Hill; 2010.

See Also (Topic, Algorithm, Electronic Media Element)

  • Congestive Heart Failure
  • Cor Pulmonale
  • Deep Vein Thrombosis
  • Angioedema
  • Cirrhosis
  • Venous Insufficiency
  • Nephritic Syndrome
  • Nephrotic Syndrome

Codes

ICD9

  • 782.3 Edema
  • 992.7 Heat edema
  • 995.1 Angioneurotic edema, not elsewhere classified

ICD10

  • R60.9 Edema, unspecified
  • T67.7XXA Heat edema, initial encounter
  • T78.3XXA Angioneurotic edema, initial encounter
  • R60.1 Generalized edema

SNOMED

  • 267038008 edema (finding)
  • 41291007 angioedema (disorder)
  • 55017000 Heat edema (disorder)
  • 271808008 edema, generalized (finding)
  • 274724004 Localized edema (finding)
  • 284521000 pitting edema (finding)
  • 420435001 Non-pitting edema (finding)
  • 56977002 Idiopathic edema (disorder)