Quincke's edema and anaphylaxis: first aid and treatment in Tashkent

What is Quincke's edema and how does it differ from urticaria?

Urticaria and angioedema are related conditions, but develop at different depths. With urticaria, fluid leaks into the surface layers of the skin, and itchy blisters appear, similar to a nettle burn; they migrate and disappear without a trace within hours. With Quincke's edema, the process occurs in the deep layers of the skin and submucosal layer, so it looks and feels different.

• The swelling is dense, bursting, and not itchy: burning, tension and pain are more often felt
• As a rule, asymmetrical: half the lip, one eyelid, one cheek swells
• The skin over the swelling is normal or slightly pale rather than bright red
• Lasts longer than urticaria - up to several days
• Favorite places: lips, eyelids, tongue, cheeks, ears, hands and feet, genitals
• Swelling of the intestinal mucosa is not manifested externally, but by severe cramping pain in the abdomen, vomiting and diarrhea; this picture is often mistaken for surgical

A separate and main danger is laryngeal edema. It gives very characteristic signs: first the voice changes, hoarseness appears, then a feeling of a lump and constriction in the throat, a barking cough, difficult noisy inhalation. This condition develops in minutes and requires immediate help. Under no circumstances should you wait to see if it will “go away on its own” in this situation.

Anaphylaxis: how to recognize it in a minute

Anaphylaxis is not a “severe skin allergy,” but a reaction that involves multiple systems at once. Doctors recognize it based on a simple principle: acute damage to the skin and mucous membranes plus breathing problems or a drop in pressure. The second option is the rapid appearance of symptoms from two or more systems after contact with a probable allergen, even without skin manifestations. The third is a sharp drop in pressure after contact with a known allergen.

• Skin: widespread urticaria, redness, itching of palms, feet and scalp, swelling
• Breathing: hoarseness, cough, wheezing, shortness of breath, nasal congestion and sneezing at first
• Blood circulation: weakness, dizziness, pallor, cold sweat, rapid weak pulse, fainting
• Abdomen: cramping pain, nausea, vomiting, diarrhea - especially with food allergies and bites
• General: a feeling of impending disaster, anxiety, in children - sudden lethargy and drowsiness

It is important to know that there may be no skin manifestations at all: in approximately some patients, anaphylaxis occurs without a rash, and this is one of the reasons why it is recognized late. In young children, the picture is even less obvious - sudden pallor, lethargy, refusal to play and vomiting come to the fore. The speed of development depends on the route of entry of the allergen: the reaction to an injection or bite develops faster than to food.

First aid: adrenaline, not an antihistamine

The procedure for dealing with anaphylaxis has been worked out and should not change depending on what is at hand. The main mistake at the prehospital stage is trying to get by with an antihistamine or hormone, because “adrenaline is scary.” Meanwhile, it is the delay in the administration of adrenaline that is associated with the most severe outcomes, and it itself is safe when administered correctly intramuscularly.

1. Немедленно вызвать скорую помощь и прекратить поступление аллергена: остановить введение препарата, удалить жало, прекратить еду.
2. Ввести адреналин внутримышечно в переднебоковую поверхность бедра — это делает медработник или сам пациент с помощью назначенного врачом автоинъектора. Через бедро препарат всасывается быстрее всего.
3. Уложить человека на спину и приподнять ноги. Резко сажать и тем более поднимать на ноги нельзя: при низком давлении это может привести к остановке кровообращения. При затруднении дыхания разрешают полусидячее положение, при рвоте — поворачивают на бок.
4. Обеспечить доступ воздуха, расстегнуть воротник и пояс, не оставлять человека одного ни на минуту.
5. При отсутствии эффекта дозу адреналина повторяют через 5–15 минут — решение принимает медработник.
6. Антигистаминные и гормоны применяются как дополнение, после адреналина: они уменьшают кожные проявления и снижают риск повторной волны, но жизнь спасает не они.

It’s worth saying separately what not to do. Do not give food or drink to a person with breathing problems or give tablets if they have difficulty swallowing. Do not try to “bring down the swelling” with cold on your own. Do not waste time measuring pressure if the picture is already clear. And do not refuse to call an ambulance if it becomes easier - this is the most common cause of subsequent complications.

Why is a hospital still needed after improvement?

It seems logical: the reaction has been removed, the person feels normal, which means he can go home. But anaphylaxis has an unpleasant property - a biphasic course. In some patients, a few hours after complete resolution of symptoms, the reaction returns without any new contact with the allergen, and the second wave may be more severe than the first. This is why after an episode of anaphylaxis a person is observed rather than released immediately.

• A repeated wave most often develops in the first hours after the episode, but later cases have also been described
• The duration of observation is determined by the doctor: it depends on the severity of the reaction, on how many doses of adrenaline were required, and on the presence of asthma
• After the episode, it is advisable to determine the level of tryptase in the blood - this test is informative in the first hours and helps confirm that the reaction was indeed anaphylactic
• Before discharge, the person should receive a written plan of action and understand for which symptoms the next time epinephrine should be given
• A mandatory follow-up is a scheduled consultation with an allergist to determine the cause: without this, the risk of recurrence remains

It is not always possible to establish the cause, but you need to look for it. The most common culprits are foods, drugs and hymenoptera venom. Less commonly, the reaction is caused by physical activity after eating, cold, latex. If the cause cannot be found, the condition is called idiopathic, and the tactics in this case are built around constant readiness for a reaction. Separately, we note: for allergies to bee and wasp venom, there is venom immunotherapy, which radically reduces the risk of a repeat severe reaction, and this is the case when treatment actually solves the problem, and not just mitigates it.

Edema without allergies: hereditary angioedema and reaction to blood pressure medications

Not every angioedema is allergic, and this is important because non-allergic forms do not respond to adrenaline, hormones and antihistamines. You can suspect them based on several signs.

• Hereditary angioedema: edema without urticaria and without itching, repeated since childhood or adolescence, there are similar cases in relatives, often provoked by trauma, dental intervention, stress
• It is characterized by attacks of severe abdominal pain with vomiting due to intestinal edema - such patients are often operated on by mistake
• Edema in this disease develops more slowly than an allergic one - within hours - and lasts longer, up to several days.
• The reason is a deficiency or dysfunction of a special protein, C1 inhibitor; The diagnosis is made by blood tests, and treatment is carried out with special drugs
• Angioedema due to angiotensin-converting enzyme inhibitors, common blood pressure medications. It may occur for the first time after months or even years of continuous use, so the connection with the drug is often not noticed
• The typical picture in this case is swelling of the lips, tongue and pharynx without urticaria and without itching; the drug is completely discontinued and no longer prescribed

The practical conclusion for the patient is simple: if edema recurs, but there is no hives or itching, be sure to tell the doctor about all medications taken and about cases of similar edema in the family. This changes both the examination and treatment entirely. With hereditary angioedema, the family should have a plan in case of an attack, and before any dental or surgical procedure, prophylaxis prescribed by the doctor is carried out.

Life after the episode: how to reduce the risk

1. Точно установить причину у аллерголога и получить перечень того, что исключается, включая перекрёстно реагирующие вещества и скрытые источники аллергена.
2. Обсудить с врачом возможность иметь при себе средство экстренной помощи и научиться им пользоваться — вместе с членами семьи, а не в одиночку.
3. Хранить письменный план действий там, где его найдут: в телефоне на экране блокировки, в кошельке, у классного руководителя, у коллег.
4. Носить опознавательный браслет или карточку с указанием аллергена — в бессознательном состоянии это единственный источник информации для медиков.
5. Держать под контролем бронхиальную астму, если она есть: плохо контролируемая астма ухудшает исход анафилаксии.
6. Предупреждать врачей и стоматологов о реакции при каждом обращении и перед любой процедурой.
7. При аллергии на яд насекомых — обсудить иммунотерапию, а до неё соблюдать простые меры: не пить сладкие напитки of открытых банок на улице, не ходить босиком по траве, не размахивать руками при появлении осы.

It is worth discussing the scenario separately with the children. A child with confirmed food anaphylaxis should be under the supervision of not only parents: the school or kindergarten must know what exactly is not allowed, where the drug is and what to do at the first signs of a reaction. Practice shows that written instructions work much better than verbal warnings. And one more thing: teenagers tend to hide their diagnosis and take risks “for company” - you should talk to them about this directly, explaining the mechanics of risk, and not intimidating.