How is swelling treated?

Treatment of Swelling: A Comprehensive Approach

The treatment of swelling depends entirely on its underlying cause, with specific targeted therapies ranging from elevation and ice for minor injuries to medications like epinephrine for life-threatening angioedema. 1

Identifying the Type of Swelling

Before initiating treatment, it's crucial to identify the type of swelling:

Hereditary Angioedema (HAE)

• Characterized by episodic swelling lasting 24-72 hours
• Often affects extremities, abdomen, face, and potentially life-threatening if in oropharynx/larynx
• Not responsive to standard treatments like antihistamines, corticosteroids, or epinephrine 1

Traumatic/Injury-Related Swelling

• Typically localized to injury site
• Often accompanied by pain, bruising, or limited mobility 2

Frostbite-Related Swelling

• Occurs after rewarming of frozen tissue
• Accompanied by numbness, tingling, pain, and skin color changes 1

Cerebral/Cerebellar Swelling

• Medical emergency requiring specialized neurological care
• Accompanied by altered mental status, pupillary changes 1

Anaphylactic Swelling

• Rapid onset, potentially life-threatening
• Often accompanied by respiratory distress, hypotension 3

Treatment Approaches by Swelling Type

1. Hereditary Angioedema (HAE)

First-line treatment for acute attacks:

• Plasma-derived C1 inhibitor (C1INH)
• Ecallantide (plasma kallikrein inhibitor)
• Icatibant (bradykinin B2 receptor antagonist) 1

Important considerations:

• Standard angioedema treatments (epinephrine, corticosteroids, antihistamines) are not effective for HAE 1
• Fresh frozen plasma may help but carries risk of worsening symptoms 1
• Administer treatment as early as possible in an attack 1

For short-term prophylaxis (before procedures):

• C1INH replacement (1000-2000 U or 20 U/kg for children)
• Have on-demand acute treatment drugs readily available 1

For long-term prophylaxis:

• Plasma-derived C1INH (1000 U every 3-4 days)
• 17α-alkylated androgens (at lowest effective dose)
• Antifibrinolytic drugs (less effective option) 1

2. Traumatic/Injury-Related Swelling

Immediate management (RICE protocol):

• Rest the affected area
• Ice application (20 minutes on, 20 minutes off)
• Compression with elastic bandage
• Elevation above heart level 2

Medication options:

• NSAIDs (ibuprofen, naproxen) to reduce inflammation and pain
• Acetaminophen for pain relief without anti-inflammatory effect 2

Physical therapy interventions:

• Ultrasound therapy for moderate to severe cases
• Electrical stimulation methods
• Therapeutic exercises once inflammation is controlled 2

3. Frostbite-Related Swelling

Immediate management:

• Remove constricting items (jewelry, tight clothing)
• Protect frozen tissue from further injury
• Apply clean, dry, bulky dressings loosely 1

Medication options:

• NSAIDs (particularly ibuprofen) to decrease vasoconstriction and tissue damage 1

Important considerations:

• Leave intact epidermal layers undisturbed
• Avoid using frostbitten extremities for walking or climbing
• Prioritize core rewarming in hypothermic individuals before treating frostbite 1

4. Cerebral/Cerebellar Swelling

Medical management:

• Elevation of head of bed to 30°
• Osmotic therapy with mannitol or hypertonic saline for patients with clinical deterioration 1
• Close neurological monitoring for deterioration 1

Surgical options:

• Decompressive craniectomy for hemispheric infarcts with significant swelling
• Suboccipital craniectomy for cerebellar infarcts with brainstem compression 1

Important considerations:

• Hypothermia, barbiturates, and corticosteroids are not recommended 1
• Early neurosurgical consultation is crucial 1

5. Anaphylactic Swelling

First-line treatment:

• Intramuscular epinephrine (0.3-0.5 mg in adults, 0.01 mg/kg up to 0.3 mg in children) administered in the anterolateral thigh 3

Secondary treatments:

• H1 antihistamines, H2 antihistamines, and corticosteroids for symptom management
• Remove stinger if present (insect sting cases)
• Clean wound thoroughly 3

Important considerations:

• Never delay epinephrine administration for secondary treatments
• Observe patients for 4-6 hours after treatment
• Consider antibiotics for immunocompromised patients or with moderate to severe injuries 3

Common Pitfalls and Caveats

1. Misdiagnosis of HAE: Standard angioedema treatments (epinephrine, corticosteroids, antihistamines) are ineffective for HAE. Using specific HAE medications is crucial. 1

2. Injecting corticosteroids into potentially infected joints: Never inject corticosteroids into a swollen joint until infection has been ruled out. 4

3. Delayed treatment of cerebral swelling: Early recognition and intervention are critical to prevent permanent brain damage or death. 1

4. Inappropriate frostbite management: Rewarming frostbitten extremities before addressing core hypothermia can worsen outcomes. 1

5. Overlooking systemic causes: Lower extremity swelling may be due to systemic conditions rather than local issues. 5, 6

6. Delayed epinephrine in anaphylaxis: Secondary treatments should never delay epinephrine administration in anaphylaxis. 3

By identifying the specific cause of swelling and implementing the appropriate targeted therapy, clinicians can effectively manage this common clinical presentation and improve patient outcomes.