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, 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 heat
  - More common in women
  - Not necessarily related to menses

Etiology

Generalized:
- Heart failure
- Cor pulmonale
- Cardiomyopathies
- Constrictive pericarditis
- Pulmonary HTN:
  - Sleep apnea
  - COPD
- Acute glomerulonephritis
- Renal failure
- Medication related (often secondary to salt retention):
  - Steroids/estrogens/progestins
  - NSAIDs
  - Antihypertensives (especially vasodilators)
  - Lithium
  - Cyclosporine
  - Insulin
  - Thiazolidinediones (glitazones)
  - Growth hormone
  - Interleukin-2
  - MAOIs
  - Pramipexole
  - Docetaxel
  - Minoxidil
  - Acute withdrawal of diuretics
- Idiopathic (cyclic) edema
- Myxedema
- Cirrhosis
- Nephrotic syndrome
- Protein-losing enteropathy/malabsorption
- Starvation
- Pregnancy
Localized:
- Deep vein thrombosis
- Venous insufficiency
- Thrombophlebitis
- Chronic lymphangitis
- Cellulitis
- Baker cyst
- Vasculitis
- Angioedema:
  - Allergic
  - Acquired
- Hypothyroidism (myxedema)
- Mechanical trauma
- Thermal injuries
- Radiation injuries
- Chemical burns
- Hemiplegia
- Reflex sympathetic dystrophy
- Compressive or invasive tumor
- Postsurgical resection of lymphatics
- Postirradiation
- Filariasis

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:
  - Feet
  - Sacrum
  - Bilateral lower extremities
  - Face/periorbital (especially in the morning)
- Cardiac:
  - Dyspnea
  - Orthopnea
  - Paroxysmal nocturnal dyspnea
  - Increased jugular venous pressure
  - Rales
  - S3 gallop
- Renal:
  - Anorexia
  - Puffy eyelids
  - Frothy urine
  - Oliguria
  - Dark urine
  - Hematuria
  - HTN
- Hepatic:
  - Jaundice
  - Spider angiomas
  - Palmar erythema
  - Gynecomastia
  - Testicular atrophy
  - Ascites
- 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
- Idiopathic:
  - Diurnal weight gain/loss
Localized:
- Chronic venous insufficiency:
  - Chronic pitting
  - Skin discoloration (hemosiderin deposits)
  - Dermatitis/ulceration
  - Varicose veins
- History of trauma:
  - Mechanical, thermal, radiation
- Infectious/inflammatory:
  - Chills
  - Fever
  - Erythema
  - Increased warmth
- Allergic:
  - Pruritus
  - Hives
  - Involvement 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 pregnancy
- From 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:
- BNP or NT-proBNP
Deep vein thrombosis suspected:
- d-dimer (for patients with low clinical probability to rule out DVT)
Renal etiology suspected:
- Electrolytes
- BUN and creatinine
- Urinalysis
- Urine electrolytes and protein
- Serum lipids
Hepatic etiology suspected:
- Serum albumin
- Liver function tests
- Prothrombin time and partial thromboplastin time
Myxedema suspected:
- Thyroid function tests

Imaging

Cardiac etiology suspected:
- EKG
- CXR
- ECG
Localized edema to an extremity:
- US (duplex scanning) or contrast venography
High suspicion for abdominal or pelvic malignancy:
- Abdominal/pelvic CT

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.

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)

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