Fool me once....

[Bostonredsox]

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So a while back, I posted an M and M case I had as a pgy2 on an angioedema case that was admitted to be "observed", crashed within 30 minutes and ended up trached emergently at bedside after failed attempts at VL by the gas attending. I forget what the thread was called so I cant link it. Well part of the aftermath of that was people bitching about the chain of events that led to the pts near demise. I had made a case that he should have been prophylacticly intubated before he completely occluded, was told no its ok to observe for now. In hindsight everyone else ended up agreeing....but it appears practice management has not changed much....

so tonight....I am called to ED for a stroke pt. Look at the tracking board and notice an 80 somethign year old with a dispo-admit label. DX angioedema. Hmmm.. no one called me for any such pt. Look at nurse note quick, pt with orders from hospitalist to admit to observation unit. hmmm...

On my way to see stroke pt, who was totally psychotic and faking the neurologic defecits it turns out, which was awesome, I pop in to this old guys room. He can talk but is difficult to understand because of his tongue swelling. Lower lip is massively swollen. He can open his mouth relatively well, but I can barely see the uvula, which is edematous, posterior pharynx is edematous and tongue is massive. of course pt is on an ACEI. Wife says this all started about 5 hours ago. Not dyspenic, but having trouble swallowing. Give my attending a quick call, who had not yet seen pt, floor senior resident had accepted pt over phone from ED doc but had not made it down to see them yet. "This guy should be moved to the unit and should be intubated now, before he decompensates in 5 hours and I cannot intubate him. He agrees immediately. I call anesthesia to bring their glide, we are without VL in micu until the new mcgrath gets here, plus I wanted their backup anyway. Also call Gen Surg to come be at bedside. Brace myself a bit for the bitchfest of why do we have to come in, your over reacting, we can just watch him from the old crotchety gas attending. surgeon texts me hed be right in. Gas attending comes in while CRNA is prepping and takes a quick look, rolls his eyes, and gives the CRNA the 'stupid medicine resident wtf did he have you call me" . Surgeon has trach kit at bedside. they prop/succ RSI him, go in with glide, very tight opening with the swollen lips, large amounts of edema in the posterior pharynx, cords swollen but can be visualized. takes him a minute or so but is able to pass tube. I tell everyone thanks for the help, propofol gtt and were gtg.

CRNA actually shakes my hand after everyone is out of the room and says, great call, if he rapid responsed in 3 hours after completelly swelling his airway shut, you and i would have both been ****ed and hed have died. Surgeon says something similar, but he had to come in for something else anyway so I gave that a pass. Gas attending said a curt, "good job", to everyone and then walked out immediately after tube had been passed.

So.

Was I too hasty having him and surgeon called in at bedside at midnight for an airway that ended up not being too terribly hard? I have had 3 of these such pts now. The first two were "observed", and both ended up emergently trached after they crashed. My gut instinct is that presumed ACEI induced angioedema with pharyngeal edema and a potentially threatened airway, EVEN IF THEIR RESPIRATORY STATUS IS STABLE CURRENTLY, should always be prophylacticly intubated, ideally fiberoptically, and kept on the vent until the edema resolves. Am I overkilling this because of a few bad outcomes??

 

[Sonny Crocket]

You did the right thing bro.

 

[sevoflurane]

Was I too hasty having him and surgeon called in at bedside at midnight for an airway that ended up not being too terribly hard? I have had 3 of these such pts now. The first two were "observed", and both ended up emergently trached after they crashed. My gut instinct is that presumed ACEI induced angioedema with pharyngeal edema and a potentially threatened airway, EVEN IF THEIR RESPIRATORY STATUS IS STABLE CURRENTLY, should always be prophylacticly intubated, ideally fiberoptically, and kept on the vent until the edema resolves. Am I overkilling this because of a few bad outcomes??

You need to do what you feel is right. Every case is different.

I don't believe that patients with angioedema should "ALWAYS BE PROPHYLACTICLY INTUBATED"

Why? Becasuse I have everted this situation a handful of times in my career:

Steroids + Recemic epi + ecallantide

Every situation is different, but if you feel like an AW is what you need, then by all means... secure it.

 

[Gern Blansten]

Your patient is alive. Anybody can make it look hard. You allowed them the opportunity to intervene when it was still easy. I agree with the all hands on deck / prepared method you chose. I may not be super excited to get out of bed to come in, but, really, when would you ever be excited to come in?

 

[Idiopathic]

didnt we already beat this to death? you did well, congratulations.

i would probably intubate this patient electively because i havent seen very many of these. if my N of medically managing this greater than zero I might be inclined to take that route. i absolutely agree with having an attending at bedside for all resident intubations, so thats not really an issue. i dont hate the idea of having a surgeon at bedside, and its probably safer for the patient, but if they are coming in from home (called in?) then probably could just be ready to perc trach should you need to.

 

[VentdependenT]

You need to do what you feel is right. Every case is different.

I don't believe that patients with angioedema should "ALWAYS BE PROPHYLACTICLY INTUBATED"

Why? Becasuse I have everted this situation a handful of times in my career:

Steroids + Recemic epi + ecallantide

Every situation is different, but if you feel like an AW is what you need, then by all means... secure it.

You think that fancy ass drug works for ACEi angioedema? I doubt i could get my hands on it and I dont know how long i should wait for it to maybe kick in.

 

[sevoflurane]

You think that fancy ass drug works for ACEi angioedema? I doubt i could get my hands on it and I dont know how long i should wait for it to maybe kick in.

Sup Venty. Don't know for sure dude. Hem/onc suggested it. We used it in conjunction with racemic epi and steroids (had to overnight it from somewhere). I've avoided 2 intubations in 5 years. Had to tube a couple. The 2 we used it on, looked like balloons... I was actually thinking of calling the last one, because he documented what he looked like over the course of a week.

I want his pics as part of my, Daaammm... files.

 

[Gern Blansten]

Sup Venty. Don't know for sure dude. Hem/onc suggested it. We used it in conjunction with racemic epi and steroids (had to overnight it from somewhere). I've avoided 2 intubations in 5 years. Had to tube a couple. The 2 we used it on, looked like balloons... I was actually thinking of calling the last one, because he documented what he looked like over the course of a week.

I want his pics as part of my, Daaammm... files.

I think I have gone out with the girl on the right. I don't recognize her friend on the left.

 

[Hamhock]

So a while back, I posted an M and M case I had as a pgy2 on an angioedema case that was admitted to be "observed", crashed within 30 minutes and ended up trached emergently at bedside after failed attempts at VL by the gas attending. I forget what the thread was called so I cant link it. Well part of the aftermath of that was people bitching about the chain of events that led to the pts near demise. I had made a case that he should have been prophylacticly intubated before he completely occluded, was told no its ok to observe for now. In hindsight everyone else ended up agreeing....but it appears practice management has not changed much....

so tonight....I am called to ED for a stroke pt. Look at the tracking board and notice an 80 somethign year old with a dispo-admit label. DX angioedema. Hmmm.. no one called me for any such pt. Look at nurse note quick, pt with orders from hospitalist to admit to observation unit. hmmm...

On my way to see stroke pt, who was totally psychotic and faking the neurologic defecits it turns out, which was awesome, I pop in to this old guys room. He can talk but is difficult to understand because of his tongue swelling. Lower lip is massively swollen. He can open his mouth relatively well, but I can barely see the uvula, which is edematous, posterior pharynx is edematous and tongue is massive. of course pt is on an ACEI. Wife says this all started about 5 hours ago. Not dyspenic, but having trouble swallowing. Give my attending a quick call, who had not yet seen pt, floor senior resident had accepted pt over phone from ED doc but had not made it down to see them yet. "This guy should be moved to the unit and should be intubated now, before he decompensates in 5 hours and I cannot intubate him. He agrees immediately. I call anesthesia to bring their glide, we are without VL in micu until the new mcgrath gets here, plus I wanted their backup anyway. Also call Gen Surg to come be at bedside. Brace myself a bit for the bitchfest of why do we have to come in, your over reacting, we can just watch him from the old crotchety gas attending. surgeon texts me hed be right in. Gas attending comes in while CRNA is prepping and takes a quick look, rolls his eyes, and gives the CRNA the 'stupid medicine resident wtf did he have you call me" . Surgeon has trach kit at bedside. they prop/succ RSI him, go in with glide, very tight opening with the swollen lips, large amounts of edema in the posterior pharynx, cords swollen but can be visualized. takes him a minute or so but is able to pass tube. I tell everyone thanks for the help, propofol gtt and were gtg.

CRNA actually shakes my hand after everyone is out of the room and says, great call, if he rapid responsed in 3 hours after completelly swelling his airway shut, you and i would have both been ****ed and hed have died. Surgeon says something similar, but he had to come in for something else anyway so I gave that a pass. Gas attending said a curt, "good job", to everyone and then walked out immediately after tube had been passed.

So.

Was I too hasty having him and surgeon called in at bedside at midnight for an airway that ended up not being too terribly hard? I have had 3 of these such pts now. The first two were "observed", and both ended up emergently trached after they crashed. My gut instinct is that presumed ACEI induced angioedema with pharyngeal edema and a potentially threatened airway, EVEN IF THEIR RESPIRATORY STATUS IS STABLE CURRENTLY, should always be prophylacticly intubated, ideally fiberoptically, and kept on the vent until the edema resolves. Am I overkilling this because of a few bad outcomes??

Good call, Boston.

You're the best.

HH

 

[Bostonredsox]

​

Good call, Boston.

You're the best.

HH

har har thanks for the sarcasm.

i just want to do whas best for the pt. that said, i dont want to be thought of us trigger happy and inexperienced by my anesthesia counterparts. gas attendings reaction sort of had me second guessing my decision, which is unusual for m in general. but im always looking to learn

 

[dotcb]

These cases with concern of impending airway obstruction (similar to burn airways) can be tough. The tough thing is that they need serial assessment by the same person, and you have to ask the patient how they're feeling - worse breathing, worse dysphonia. Most won't need to be intubated, but you have to watch them like a hawk, and if they're progressing/worsening, then yes - do it.

I personally wouldn't have a surgeon there, but you should be ready and prepared for the possibility of a cric. Ideally these airways should be done awake.