How should an adult presenting to the emergency department with an acute Raynaud's attack be managed?

Emergency Department Management of Acute Raynaud's Attack

For an adult presenting to the ED with an acute Raynaud's attack, immediate rewarming of the affected extremity is the primary intervention, followed by assessment for digital ischemia complications and initiation of vasodilator therapy if conservative measures fail.

Immediate ED Assessment and Stabilization

Initial Evaluation

• Rapidly rewarm the affected digits using warm (not hot) water at approximately 37-40°C or by moving the patient to a warm environment and having them place hands in axillae or between thighs 1, 2
• Document the color changes (pallor, cyanosis, erythema) and duration of the attack to confirm the diagnosis clinically 1, 2
• Assess for digital ulceration, gangrene, or signs of critical ischemia requiring urgent intervention 3, 4
• Determine if this is primary (idiopathic) versus secondary Raynaud's by checking for associated symptoms of connective tissue disease including skin thickening, joint pain, dysphagia, or history of autoimmune conditions 2, 4

Critical Diagnostic Steps

• Obtain erythrocyte sedimentation rate (ESR), C-reactive protein, and antinuclear antibodies (ANA) to screen for underlying connective tissue disease, particularly if patient is over age 50 or has new-onset symptoms 3, 2
• Perform pulse examination and consider upper extremity pulse-volume recording to exclude proximal arterial obstruction as the cause 1
• Check for nailfold capillary abnormalities using dermatoscopy if available, as abnormal capillaries suggest secondary Raynaud's 2

Acute Pharmacologic Management

First-Line Vasodilator Therapy

If rewarming alone does not resolve symptoms within 15-30 minutes or if there is evidence of severe ischemia, initiate calcium channel blocker therapy immediately 3, 4, 5

• Nifedipine extended-release 30-60 mg orally is the most studied and effective first-line agent 4, 5
• Monitor blood pressure closely as hypotension, peripheral edema, and headache are common adverse effects 5

Second-Line Options for Refractory Cases

If calcium channel blockers are contraindicated or ineffective:

• Topical nitroglycerin paste applied to affected digits can provide localized vasodilation 3, 4
• Sildenafil 20-50 mg orally (phosphodiesterase-5 inhibitor) for patients with severe digital ischemia 3, 4, 5

Severe Digital Ischemia with Ulceration or Gangrene

For patients presenting with digital ulcers, gangrene, or threatened digit loss, consider admission for intravenous prostacyclin analogues 3, 4

• These patients require specialized wound care, adequate analgesia, and assessment for superimposed infection requiring antibiotics 3, 4
• Amputation may ultimately be required in cases of established gangrene or osteomyelitis 3

Disposition and Follow-Up

Discharge Criteria

Patients can be discharged if:

• Symptoms resolve completely with rewarming and/or oral vasodilators 1, 2
• No evidence of digital ulceration or critical ischemia 3
• Adequate pain control achieved 4
• Patient can avoid cold exposure and has appropriate follow-up arranged 1, 5

Admission Criteria

Admit patients with:

• Persistent severe ischemia despite ED interventions 4
• Digital ulceration or gangrene requiring IV prostacyclin therapy 3, 4
• Suspected acute arterial occlusion requiring vascular surgery consultation 1
• New diagnosis of secondary Raynaud's with systemic symptoms requiring inpatient workup 2, 4

Critical Pitfalls to Avoid

• Do not apply direct heat sources (heating pads, hot water bottles) as this can cause burns in ischemic tissue 1
• Do not dismiss symptoms in older patients or those with asymmetric involvement, as this suggests secondary causes or arterial occlusion rather than primary Raynaud's 2, 5
• Do not delay vascular surgery consultation if there is concern for acute arterial thrombosis or embolism, which requires different management than vasospastic Raynaud's 1
• Do not prescribe beta-blockers or ergot alkaloids, as these can worsen vasospasm 3, 6
• Do not overlook smoking cessation counseling, as tobacco use significantly exacerbates Raynaud's phenomenon 3, 5