Downloaded from http://emj.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Prehospital care 5
6
7 8 9
Plant PK, Owen JL, Elliott MW. One year period prevalence study of respiratory acidosis in acute exacerbations of COPD: implications for the provision of non-invasive ventilation and oxygen administration. Thorax 2000;55: 550–4. Austin MA, Wills KE, Blizzard L, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010;341:c5462. Murphy R, Driscoll P, O’Driscoll R. Emergency oxygen therapy for the COPD patient. Emerg Med J 2001;18:333–9. Roberts CM, Stone RA, Buckingham RJ, et al. Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax 2011;66:43–8. New A. Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient. Emerg Med J 2006;23:144–6.
10 11 12 13
14 15
Beasley R, Patel M, Perrin K, et al. High-concentration oxygen therapy in COPD. Lancet 2011;378:969–70. Wellington Free Ambulance Incorporated. Clinical Practice Guidelines Comprehensive Edition, 2.4 Exacerbation of CORD. 2009. Gunawardena KA, Patel B, Campbell IA, et al. Oxygen as a driving gas for nebulisers: safe or dangerous? Br Med J (Clin Res Ed) 1984;288:272–4. Edwards L, Perrin K, Williams M, et al. Randomised controlled crossover trial of the effect on PtCO2 of oxygen-driven versus air-driven nebulisers in severe chronic obstructive pulmonary disease. Emerg Med J 2011;29:894–8. O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax 2008;63(Suppl 6):vi1–68. Turner MO, Patel A, Ginsburg S, et al. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Arch Intern Med 1997;157:1736–44.
IMAGES IN EMERGENCY MEDICINE
Angina bullosa haemorrhagica rare cause of upper airway obstruction An 85-year-old woman presented to the emergency department complaining of difficulty in breathing, swollen tongue (figure 1) and inability to speak. On examination the patient was in respiratory distress and cyanotic, with oxygen saturation of 85% on 15 L of oxygen. She reported a previous but less severe episode of several blood-filled blisters on the buccal mucosa and hard palate, which had subsequently ruptured and subsided on their own. Because the large blister was causing upper airway obstruction, incision and drainage was performed (figure 2). Angina bullosa haemorrhagica is the term used to describe acute, benign, subepithelial oral mucosal blood-filled blisters.1 The differential diagnosis includes pemphigoid, epidermolysis bullosa, linear IgA and dermatitis herpetiformis or thrombocytopenia.2 No treatment is required for small-sized blisters because they spontaneously rupture and heal. Any large, intact blood blister Figure 2
Post-incision and drainage.
should be incised to prevent further enlargement that could cause airway obstruction. Rarely, tracheal intubation and surgical tracheostomy are required.3 Ravishankar Prabhakar Shashikala Correspondence to Dr Ravishankar Prabhakar Shashikala, 12, Grosvenor House, Sorbonne Close, Thornaby, Stockton on Tees TS17 6DP, UK and A&E, University Hospital of North Tees, Stockton on Tees, TS19 8PE, UK; [email protected] Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Prabhakar Shashikala R. Emerg Med J 2015;32:238. Accepted 11 June 2014 Emerg Med J 2015;32:238. doi:10.1136/emermed-2014-203848
REFERENCES 1 2 3
Figure 1 Initial presentation. 238
Badham NJ. Blood blisters and oesophageal cast. J Laryngol 1967;81:791–803. Roman C, Terry LB, et al. Angina bullosa haemorrhagica. E-medicine. 2012. http//: www.emedicine.medscape.com/article/1078960-overview Pahl C, Yarrow S, Steventon N, et al. Angina bullosa haemorrhagica presenting as acute upper airway obstruction. Br J Anaesth 2004;92:283–6.
Pilcher J, et al. Emerg Med J 2015;32:234–238. doi:10.1136/emermed-2013-203094
Downloaded from http://emj.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Angina bullosa haemorrhagica rare cause of upper airway obstruction Ravishankar Prabhakar Shashikala Emerg Med J 2015 32: 238 originally published online June 30, 2014
doi: 10.1136/emermed-2014-203848 Updated information and services can be found at: http://emj.bmj.com/content/32/3/238
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Articles on similar topics can be found in the following collections Dermatology (88) Ethics (371)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Prehospital care 5
6
7 8 9
Plant PK, Owen JL, Elliott MW. One year period prevalence study of respiratory acidosis in acute exacerbations of COPD: implications for the provision of non-invasive ventilation and oxygen administration. Thorax 2000;55: 550–4. Austin MA, Wills KE, Blizzard L, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010;341:c5462. Murphy R, Driscoll P, O’Driscoll R. Emergency oxygen therapy for the COPD patient. Emerg Med J 2001;18:333–9. Roberts CM, Stone RA, Buckingham RJ, et al. Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax 2011;66:43–8. New A. Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient. Emerg Med J 2006;23:144–6.
10 11 12 13
14 15
Beasley R, Patel M, Perrin K, et al. High-concentration oxygen therapy in COPD. Lancet 2011;378:969–70. Wellington Free Ambulance Incorporated. Clinical Practice Guidelines Comprehensive Edition, 2.4 Exacerbation of CORD. 2009. Gunawardena KA, Patel B, Campbell IA, et al. Oxygen as a driving gas for nebulisers: safe or dangerous? Br Med J (Clin Res Ed) 1984;288:272–4. Edwards L, Perrin K, Williams M, et al. Randomised controlled crossover trial of the effect on PtCO2 of oxygen-driven versus air-driven nebulisers in severe chronic obstructive pulmonary disease. Emerg Med J 2011;29:894–8. O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax 2008;63(Suppl 6):vi1–68. Turner MO, Patel A, Ginsburg S, et al. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Arch Intern Med 1997;157:1736–44.
IMAGES IN EMERGENCY MEDICINE
Angina bullosa haemorrhagica rare cause of upper airway obstruction An 85-year-old woman presented to the emergency department complaining of difficulty in breathing, swollen tongue (figure 1) and inability to speak. On examination the patient was in respiratory distress and cyanotic, with oxygen saturation of 85% on 15 L of oxygen. She reported a previous but less severe episode of several blood-filled blisters on the buccal mucosa and hard palate, which had subsequently ruptured and subsided on their own. Because the large blister was causing upper airway obstruction, incision and drainage was performed (figure 2). Angina bullosa haemorrhagica is the term used to describe acute, benign, subepithelial oral mucosal blood-filled blisters.1 The differential diagnosis includes pemphigoid, epidermolysis bullosa, linear IgA and dermatitis herpetiformis or thrombocytopenia.2 No treatment is required for small-sized blisters because they spontaneously rupture and heal. Any large, intact blood blister Figure 2
Post-incision and drainage.
should be incised to prevent further enlargement that could cause airway obstruction. Rarely, tracheal intubation and surgical tracheostomy are required.3 Ravishankar Prabhakar Shashikala Correspondence to Dr Ravishankar Prabhakar Shashikala, 12, Grosvenor House, Sorbonne Close, Thornaby, Stockton on Tees TS17 6DP, UK and A&E, University Hospital of North Tees, Stockton on Tees, TS19 8PE, UK; [email protected] Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Prabhakar Shashikala R. Emerg Med J 2015;32:238. Accepted 11 June 2014 Emerg Med J 2015;32:238. doi:10.1136/emermed-2014-203848
REFERENCES 1 2 3
Figure 1 Initial presentation. 238
Badham NJ. Blood blisters and oesophageal cast. J Laryngol 1967;81:791–803. Roman C, Terry LB, et al. Angina bullosa haemorrhagica. E-medicine. 2012. http//: www.emedicine.medscape.com/article/1078960-overview Pahl C, Yarrow S, Steventon N, et al. Angina bullosa haemorrhagica presenting as acute upper airway obstruction. Br J Anaesth 2004;92:283–6.
Pilcher J, et al. Emerg Med J 2015;32:234–238. doi:10.1136/emermed-2013-203094
Downloaded from http://emj.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Angina bullosa haemorrhagica rare cause of upper airway obstruction Ravishankar Prabhakar Shashikala Emerg Med J 2015 32: 238 originally published online June 30, 2014
doi: 10.1136/emermed-2014-203848 Updated information and services can be found at: http://emj.bmj.com/content/32/3/238
These include:
References Email alerting service
Topic Collections
This article cites 2 articles, 1 of which you can access for free at: http://emj.bmj.com/content/32/3/238#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Dermatology (88) Ethics (371)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
