A 42-year-old woman with unexplained swelling of the hand and forearm

Ten years ago, Lisa Molitor approached

the JOURNAL wi th an exc i t ing idea for a n e w

column on triage. On this, her tenth anni-

versary as sect ion editor, w e would like to

t hank Lisa for one of the JOURNAL'S m o s t

popular c o l u m n s - - E d i t o r

A 42-yea r -o ld w o m a n c a m e to the e m e r g e n c y de- p a r t m e n t w i t h g e n e r a l i z e d s w e l l i n g of t h e r i g h t

h a n d a n d forearm. This w a s he r s e c o n d v i s i t in 3 weeks . On t h e first vis i t , she s t a t e d t h a t she h a d s u s t a i n e d s l i g h t t r a u m a to t h e a r e a a n d t h e n n o t i c e d a smal l , r a i s e d a r e a t h a t w a s " b l a c k a n d b l u e , " w h i c h l ed to s w e l l i n g of t h e en t i r e r i gh t a r m s e v e r a l hou r s la ter . B e c a u s e he r w o r k w a s farm r e l a t ed , a d i a g n o s i s of ce l Iu l i t i s h a d b e e n m a d e , a n d s h e h a d b e e n a d m i t t e d to t h e h o s p i t a l for a d m i n i s t r a t i o n of IV an t ib io t i c s . H o w e v e r , he r l a b o r a t o r y t e s t r e su l t s h a d al l b e e n w i t h i n n o r m a l l im i t s a n d c u l t u r e s w e r e s ter i le . W h e n the s w e l l i n g s u b s i d e d 3 d a y s la ter , she h a d b e e n d i s c h a r g e d .

On t h e s e c o n d visi t , t h e p a t i e n t a g a i n h a d a s w o l l e n r i g h t h a n d a n d forearm. She sa id she h a d r e a c h e d for a cup of coffee a n d t h e n e x p e r i e n c e d t h e s e n s a t i o n t h a t a b l o o d v e s s e l h a d b r o k e n in he r t h i r d f inger . In i t i a l ly t h e r e w a s a s l i g h t b l u e d i s c o l o r a t i o n of t h e f inger , a n d af ter a few hours t he h a n d a n d fo rea rm b e g a n to swel l . P h y s i c a l e x a m i n a t i o n re- v e a l e d swol len , e r y t h e m a t o u s a r e a s over t he first a n d four th m e t a c a r p a l s . T h e r e w a s s l i gh t e r y t h e m a a n d w h a t a p p e a r e d to b e a r e s o l v i n g b r u i s e over t he t h i rd d ig i t . R a n g e of m o t i o n w a s l i m i t e d b e c a u s e of t he e d e m a , a n d s e n s o r y a n d moto r func t ions w e r e in tac t .

The p a t i e n t w a s a febr i le , n o r m o t e n s i v e , a n d h a d a h e a r t r a te of 82 bea t s /mAn.

Ms. Heinzerling is an instructor in the emergency department, Medical Center Hospital of Vermont, Burlington, Vermont.

What do you suspect?

Discussion The p a t i e n t h a d l a b o r a t o r y s a m p l e s d r a w n for com- p l e t e b lood cel l count , b l o o d cul ture , a n d c lo t t i ng s tud ies ; r e su l t s w e r e al l w i t h i n n o r m a l l imits . A ra- d i o g r a p h d e m o n s t r a t e d on ly soft t i s s u e s w e l l i n g a n d t h e r e w e r e no fore ign bod ie s . T h e p a t i e n t w a s q u e s t i o n e d r e p e a t e d l y a b o u t t r a u m a or c h e m i c a l exposu re , w h i c h she den i ed .

A p r e s u m e d d i a g n o s i s of a l l e r g y to farm prod- uc t s w a s m a d e , a n d the p a t i e n t w a s g i v e n d i p h e n - h y d r a m i n e . T h e e d e m a i m p r o v e d n o t i c e a b l y d u r i n g the n e x t few hours . She w a s d i s c h a r g e d w i th t h e d i a g n o s i s of " g i a n t u r t i ca r i a . " Th i s h a s b e e n de- s c r i b e d in t h e l i t e r a t u r e a s a n g i o e d e m a . It is cha r - a c t e r i z e d b y a s u d d e n o n s e t of l oca l i zed s w e l l i n g m e a s u r i n g s e v e r a l c e n t i m e t e r s in l e n g t h a n d d i a m - eter. It is typ ica l ly devo id of i tching, pain, or e ry thema. It is short l ived a n d fades w i thou t v is ib le seque lae du r ing the course of 24 to 72 hours. E d e m a of the res- p i ra tory a n d gas t ro in t e s t ina l t rac ts m a y occur; involve- m e n t of the resp i ra tory t ract m a y b e fatal.

T h e r e are two c l a s s i f i c a t i ons of a n g i o e d e m a : h e r e d i t a r y a n d acqu i r ed . The h e r e d i t a r y form usu- a l ly affects t h e g a s t r o i n t e s t i n a l a n d u p p e r r e sp i ra - tory t r ac t s a n d can s i m u l a t e a c u t e m e d i c a l a n d sur- g ica l e m e r g e n c i e s .

A d m i n i s t r a t i o n of a n t i h i s t a m i n e s and cort icoste- roAds is effective for acu te a t tacks . Obviously, pa t i en t s shou ld wear e m e r g e n c y iden t i f ica t ion wi th the d iag- nosis and desc r ib ing e l e m e n t a r y precaut ions .

Section Editor's teaching points This p a t i e n t ' s p e r p l e x i n g p r e s e n t a t i o n w o u l d have b e e n diff icul t to sor t ou t in t he t r i a g e area, b u t

For reprints, write Susanne Heinzerling, RNC, CEN, 50 Jim Dwier Rd., Bristol, VT 05443. J EMERG NURS 1995;21:86-7 Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 + 0 18/1/60711

86 Volume 21, Number 1

Heinzeri[ng/jOUl~NAL OF EMERGENCY NURSING

i n c r e a s e d a w a r e n e s s a b o u t a n g i o e d e m a c a n ce r -

t a i n l y i m p r o v e e f f i c i e n c y of p a t i e n t ca r e . Of p a r t i c -

u l a r i m p o r t a n c e in t h e p a t i e n t ' s s i t u a t i o n w a s t h e

f a c t t h a t h e r v i t a l s i g n s , e s p e c i a l l y h e r t e m p e r a t u r e ,

w e r e n o r m a l . T h i s f i n d i n g m a k e s c e l l u l i t i s a l e s s

l i k e l y d i a g n o s i s . U n e x p l a i n e d s w e l l i n g , w h i c h d o e s

n o t a p p e a r to h a v e a n i n f e c t i o u s s o u r c e , c o u l d b e a

c l u e to t h e p r e s e n c e of t h e s y n d r o m e of a n g i o e d e m a

d e s c r i b e d a b o v e . If s u c h a p h e n o m e n o n i s p r e s e n t ,

t h e p a t i e n t ' s r e s p i r a t o r y s t a t u s s h o u l d b e e v a l u a t e d ,

a n d t h e p a t i e n t s h o u l d b e q u e s t i o n e d a b o u t g a s -

t r o i n t e s t i n a l p r o b l e m s .

A v a r i e t y of m e d i c a t i o n s c a n c a u s e a n g i o -

e d e m a , a l s o c a l l e d a n g i o n e u r o t i c e d e m a . T w o of t h e

m o s t c o m m o n l y p r e s c r i b e d a r e t h e a n g i o t e n s i n -

c o n v e r t i n g e n z y m e i n h i b i t o r s a n d t h e c a l c i u m c h a n -

n e l b l o c k e r s . O b t a i n i n g a m e d i c a t i o n h i s t o r y is

a l w a y s a n i m p o r t a n t p a r t of t h e t r i a g e p r o c e s s .

Distraction: An Effective Intervention for Alleviating Pain During Venipuncture. JoAnne S. Wilson, Carolyn L. Cason, and Neena L. Grissom, Little Rock, Arkansas

Purpose: This s t u d y e v a l u a t e d t he u se fu lnes s of a dis t rac- t ion in t e rven t ion , a n i l lusion ka le idoscope , for r e d u c i n g p e r c e p t i o n of p a i n in a d u l t s u n d e r g o i n g a s h o r t - t e r m pa in p rocedu re (ven ipunc tu re ) . The s t u d y also a s s e s s e d t h e a p p r o p r i a t e n e s s of t he Wong-Bake r FACES pa in assess - m e n t i n s t r u m e n t ( d e v e l o p e d for u se w i th ch i ld ren ) for m e a s u r i n g pa in in adul ts .

Design, samples, andmethods:Aconveniencesample(n = 97) of p a t i e n t s in a family p rac t i ce c l inic was u s e d for th i s s tudy. P a t i e n t s we re r a n d o m l y a s s i g n e d to e i t he r a control g roup (n = 61 ), w i t h v e n i p u n c t u r e pe r fo rmed in t he usua l m a n n e r , or to a n e x p e r i m e n t a l g roup (n = 46), w i t h veni- p u n c t u r e done wh i l e sub jec t s looked t h r o u g h a kale ido- scope. All sub jec t s we re b e t w e e n 21 a n d 65 years old (n = 42; SD = 12); t h e r e we re 25 m e n a n d 72 w o m e n . T h e sub jec t s h a d a n a v e r a g e of 14 yea r s of e d u c a t i o n (SD ~ 3). The rat io of w h i t e p a t i e n t s to b l ack p a t i e n t s was a b o u t 2:1.

The g roups we re found to b e e q u i v a l e n t w i t h r ega rd to such v a r i a b l e s as age, educa t ion , p rev ious v e n i p u n c - ture h~story, a n d e thnic i ty . Pa in pe rcep t ion w a s a s s e s s e d before a n d af ter v e n i p u n c t u r e w i t h the Wong-Baker FACES pa in a s s e s s m e n t scale, Visua l Ana log Scale (VAS) for pain, a n d t h e P re sen t Pa in I n t e n s i t y scale (PPI). Before the test , sub j ec t s r epor t ed h o w t h e y t h o u g h t v e n i p u n c t u r e wou ld feel; af ter t he p rocedure , t h e y i n d i c a t e d h o w veni- p u n c t u r e ac tua l ly felt.

Results: Ana lys i s of covar iance e v a l u a t e d pos t t e s t differ- ences . P o s t v e n i p u n c t u r e scores s e r v e d as the d e p e n d e n t var iable , a n d p r e v e n i p u n c t u r e scores were u s e d as cova- r iates. T h e ana lys i s r evea l ed t h a t pe rcep t ion of pa in was s ign i f ican t ly r e d u c e d for sub jec t s w h o used the dis t rac- t ion in t e rven t ion . T h e s ta t i s t i ca l d a t a were as follows: FACES: F = 14, d f = 1,93; p < 0.01; VAS: F = 2.6, d f = 1,93; p = 0.02; PPI: F = 13, d f = 1,93; p < 0.01. Correla- t ions a m o n g t h e t h r ee pa in a s s e s s m e n t sca les were h i g h (VAS a n d PPI, r = 0.66; VAS a n d FACES, r ~ 0.67; PPI a n d

FACES, r ~ 0.79), a n d all cor re la t ions were s ign i f ican t (p < 0.01 ). T h e s e f ind ings s u g g e s t t h a t the FACES scale, a s imp le i n s t r u m e n t w i t h low l i t e racy d e m a n d , can b e u s e d to m e a s u r e pa in pe rcep t ion in adul ts .

Conclusion: Venipunc tu re , of ten c o n s i d e r e d a " rou t ine ED p rocedure , " is a n a n x i e t y - p r o v o k i n g procedure . For pa- t i en t s w h o are a l r eady in a v u l n e r a b l e state, l ike m o s t pa- t i en t s s e e n in t h e e m e r g e n c y d e p a r t m e n t , a s imple, inde- p e n d e n t n u r s i n g i n t e r v e n t i o n such as d i s t rac t ion w i th a ka le idoscope can he lp to m a k e a c o m m o n e x p e r i e n c e - - v e n i p u n c t u r e - - l e s s d i s t ress ing . T h e ease a n d s impl ic i ty of u s i n g t h e FACES pa in a s s e s s m e n t scale m a k e it a valu- ab le tool in a cl inical s e t t i n g l ike t h e e m e r g e n c y depar t - men t .

J EMERG NURS 1995;21:87 Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 4- 0 18/3 /61610

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