kiddo with severe angioedema in ED

[hypnosisdoc]

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responded to code 99 to ED for this kid, 21mo, with severe angioedema (swelling lips and tongue, neck), copious oral secretion and agitation

standard tx for angioedema given to patient by ped ED doc, patient sat stable between 95 to 100%, no bradycardia.

how would you guys this airway emergency if patient started to desat? intubate vs. crico vs. trach? if intubate, awake? how you deal with likely edema?

 

[UTSouthwestern]

responded to code 99 to ED for this kid, 21mo, with severe angioedema (swelling lips and tongue, neck), copious oral secretion and agitation

standard tx for angioedema given to patient by ped ED doc, patient sat stable between 95 to 100%, no bradycardia.

how would you guys this airway emergency if patient started to desat? intubate vs. crico vs. trach? if intubate, awake? how you deal with likely edema?

Roll kid to the OR with mom/dad to keep him/her as calm as possible, have ENT in room ready to go, gentle mask induction with kid in whatever position he/she is comfortable in (usually sitting up), with in-line epi neb, take ONE look to see if it will be possible to intubate. If so, make it happen. If not, get ENT to start cutting.

 

[Lizard1]

Roll kid to the OR with mom/dad to keep him/her as calm as possible, have ENT in room ready to go, gentle mask induction with kid in whatever position he/she is comfortable in (usually sitting up), with in-line epi neb, take ONE look to see if it will be possible to intubate. If so, make it happen. If not, get ENT to start cutting.

so you're saying treat just like acute epiglottitis? considering kid is stable right now and has been given judicious prophylactic therapy by the ED physician, is it unwise to watch him closely and possibly not have to manipulate his airway at all? I guess it depends on the natue of the angioedema and if it is expected to resolve with treatment or be continuous?

hmmm, interesting case none the less

 

[UTSouthwestern]

so you're saying treat just like acute epiglottitis? considering kid is stable right now and has been given judicious prophylactic therapy by the ED physician, is it unwise to watch him closely and possibly not have to manipulate his airway at all? I guess it depends on the natue of the angioedema and if it is expected to resolve with treatment or be continuous?

hmmm, interesting case none the less

Yes. He's stable now, but respiratory failure is likely impending especially given the degree and extent of swelling. If the kid gets even a little anxious, everything goes to hell in a handbasket.

Get him to the OR while he's stable and get an airway secured ASAP.

 

[hypnosisdoc]

well, the patient was stable for now. he was actually admitted to ped ICU for close monitor. didn't hear anything afterwards assuming he's been stable and edema resolving. here are a few questions i have,

- the kid actually had a working IV by the time i arrived. what medications would you use to sedate/intubabe the patient?

- i didn't see any source of volatile agents in the ED. if impossible to put in IV, would you go with IM medication? what would you use?

- while i was discussing the risk of intubation attempt in this kid, the ED doc was talking about cricothyrotomy. two questions i had were, 1) i thought cricothyrotomy typically not done in kids under 10y/o (morgan); 2) since there was no jet ventilator in ED, what benefit would a crico provide?

- while patient was monitored in ICU, i personally think it's risky to wait and see. I told ped doc to call ENT/OR for standby. Anything else you'd recommend to ped doc?

Yes. He's stable now, but respiratory failure is likely impending especially given the degree and extent of swelling. If the kid gets even a little anxious, everything goes to hell in a handbasket.

Get him to the OR while he's stable and get an airway secured ASAP.

 

[Noyac]

This case must go to the OR pronto. Kids airways close fast (remember the radius of the childs airway compared to an adult) and with angioedema it can go real fast.

No IV induction (unless you have lost the airway and then it muscle relaxants only). This is a Sevo mask induction in my book with ENT ready.

I would HATE to see this case at my doorstep.

My only real pucker case of angioedema was an adult. We got on the elevator in the ER w/c went straight to the OR 1 floor up with a lady that could speak fine. By the time the elevator doors opened in the OR she could barely speak and by the time we were in the OR she couldn't breath. All this in a matter of minutes, maybe 5minutes. My attending pushed 10cc propofol and I pushed the tube through the only shadow I could see. I got very lucky that night.