managment of severe angioedema

[igcgnerd]

45 YO F presents to ED w/ severe angioedema after eating dinner. No known food allergies. Pt has multiple allergies to tetorcyclin and sulfa. Upon examination pt has a pulse of 150, RR 30, pulse ox 96% on NRB, bp 200 systolic. Severe tongue swelling, unable to close mouth. Pt appears to be in a large amount of distress, diaphoretic. Push sub q epi/ methyprednisone/ diphenylhydramine, start breathing treatment. PT mildly improves but still in severe distress.
Page ENT and anestesia, they visualize her airway fiberopticly through the nose. According to them, edema confinded to the tonugue, minimal in the posterior pharnyx and epiglotis aka airway stable.
Pt begins to stabilize, sat'ing good on a nrb, bp goes down to 130 systolic, admitted to ICU stable and alert.
Would you guys have done anything different?

---

Members don't see this ad.

 

[Aloha Kid]

I thought the management was just fine.

You could also use Pepcid as an H2 blocker adjunct.

The trouble is knowing if this was an allergic reaction angioedema vs. hereditary vs. C1 esterase deficiency. You would expect prior history for the later two.

This is what emedicine says . . .

* Hereditary angioedema is more refractory to the use of subcutaneous epinephrine, antihistamines, and steroids.
* Stanozolol, an anabolic steroid, and danazol, a gonadotropin inhibitor, may be used for the acute phase of an attack of hereditary angioedema.
* Often, patients are given aminocaproic acid for maintenance replacement of C1INH to prevent attacks. C1INH replacement should be attempted during the acute phase. If C1INH concentrate is unavailable, fresh frozen plasma may be used in the interim.

I've never had to use these meds before.

The key other issue is being prepared to manage these airways. If it got any worse, I would have probably tried awake nastracheal fiberoptic guided intubation first, then ? oral intubation try, then Cric.

 

[Apollyon]

* Stanozolol, an anabolic steroid

a/k/a the horse steroid that Ben Johnson used to shoot into his ass.

 

[domer621]

a/k/a the horse steroid that Ben Johnson used to shoot into his ass.

aka Winny... it's a fairly weak anabolic steroid.

 

[elwademd]

45 YO F presents to ED w/ severe angioedema after eating dinner. No known food allergies. Pt has multiple allergies to tetorcyclin and sulfa. Upon examination pt has a pulse of 150, RR 30, pulse ox 96% on NRB, bp 200 systolic. Severe tongue swelling, unable to close mouth. Pt appears to be in a large amount of distress, diaphoretic. Push sub q epi/ methyprednisone/ diphenylhydramine, start breathing treatment. PT mildly improves but still in severe distress.
Page ENT and anestesia, they visualize her airway fiberopticly through the nose. According to them, edema confinded to the tonugue, minimal in the posterior pharnyx and epiglotis aka airway stable.
Pt begins to stabilize, sat'ing good on a nrb, bp goes down to 130 systolic, admitted to ICU stable and alert.
Would you guys have done anything different?

I thought the management was just fine.

You could also use Pepcid as an H2 blocker adjunct.

The trouble is knowing if this was an allergic reaction angioedema vs. hereditary vs. C1 esterase deficiency. You would expect prior history for the later two.

This is what emedicine says . . .

* Hereditary angioedema is more refractory to the use of subcutaneous epinephrine, antihistamines, and steroids.
* Stanozolol, an anabolic steroid, and danazol, a gonadotropin inhibitor, may be used for the acute phase of an attack of hereditary angioedema.
* Often, patients are given aminocaproic acid for maintenance replacement of C1INH to prevent attacks. C1INH replacement should be attempted during the acute phase. If C1INH concentrate is unavailable, fresh frozen plasma may be used in the interim.

I've never had to use these meds before.

The key other issue is being prepared to manage these airways. If it got any worse, I would have probably tried awake nastracheal fiberoptic guided intubation first, then ? oral intubation try, then Cric.

good job. you put the patient in perfect position to get to the icu safely, and let us medicine (or immuno/allergy) folks take the time to figure out the allergic reaction vs hereditary angioedema vs c1 esterase deficiency.

aka Winny... it's a fairly weak anabolic steroid.

then perhaps ben should get his '88 gold medal back. 😛

 

[southerndoc]

a/k/a the horse steroid that Ben Johnson used to shoot into his ass.

Stocked in hospital code carts everywhere.

 

[Apollyon]

Stocked in hospital code carts everywhere.

Hmm...I have to look more closely, then!

 

[docB]

For those of us in the community without ENT, anesthesia or bronch or NP scopes it gets a little trickier. I had one a few years back. Ultramorbidly obese woman with angioedema and no IV access. I'm drilling for oil everywhere I can (no US either) trying to get a line as she's crumping. I wind up getting a subclavian in her. By that time she's very altered and dropping her sats. Situation rapidly turning to crap. Tried to tube. She's still fighting too much. RSI. Try to tube. Too much edema. Did a needle cric with a retrograde intubation which worked really well. About that time the subclavian failed because it pulled out of the vein. Too much fat between the skin and the vein. I finally got a central line in the left IJ although it was probably really in the EJ but I was willing to take what I could get. The whole thing was really a nightmare scene.

 

[EctopicFetus]

for the c1 esterase how about ffp? I have heard this might be a decent option for these people of course when they crump, they crump like docbs pt.

 

[elwademd]

for the c1 esterase how about ffp? I have heard this might be a decent option for these people of course when they crump, they crump like docbs pt.

This is what emedicine says . . .

* Often, patients are given aminocaproic acid for maintenance replacement of C1INH to prevent attacks. C1INH replacement should be attempted during the acute phase. If C1INH concentrate is unavailable, fresh frozen plasma may be used in the interim.

👍

 

[DrQuinn]

For those of us in the community without ENT, anesthesia or bronch or NP scopes it gets a little trickier. I had one a few years back. Ultramorbidly obese woman with angioedema and no IV access. I'm drilling for oil everywhere I can (no US either) trying to get a line as she's crumping. I wind up getting a subclavian in her. By that time she's very altered and dropping her sats. Situation rapidly turning to crap. Tried to tube. She's still fighting too much. RSI. Try to tube. Too much edema. Did a needle cric with a retrograde intubation which worked really well. About that time the subclavian failed because it pulled out of the vein. Too much fat between the skin and the vein. I finally got a central line in the left IJ although it was probably really in the EJ but I was willing to take what I could get. The whole thing was really a nightmare scene.

Ugh, that sounds horrific! Why did you pick a retrograde tube over just a cric? Was her neck just way too thick?

Yuckie! Haven't had any of those yet...

But to the OP I think management was appropriate. Given steroids and such, and I usually throw in an H1 blocker but those are more for "show and tell" and in my 20-30 cases of angioedema they never get better with those. Half of mine have to be intubated via nasal scope. "Just go for the bubbles."

Q

 

[igcgnerd]

It was a pain in the ***** to get ENT to come in. They showed up 3 hours later. Anesthesia on call was in house and showed up at a run ready to atempt a fiberoptic. He was the kind of guy who can really run in and help people when it hits the fan. But in response to some earlier comments there was a cric tray at bedside as soon as the person came in.

 

[tkim]

It was a pain in the ***** to get ENT to come in. They showed up 3 hours later. Anesthesia on call was in house and showed up at a run ready to atempt a fiberoptic. He was the kind of guy who can really run in and help people when it hits the fan. But in response to some earlier comments there was a cric tray at bedside as soon as the person came in.

Which program are you at?

 

[docB]

Ugh, that sounds horrific! Why did you pick a retrograde tube over just a cric? Was her neck just way too thick?

I was still able to bag her enough to keep the sats in the 80s. I just wasn't quite at the "can't intubate, can't ventilate" situation that indicates a cric. I have found that the needle cric with a retrograde tube is a great fallback when you can still bag some but for various reasons really have to get the tube, ie. falling back to letting them breathe and trying to fix the underlying problem just isn't an option. It's relatively easy to do (I've done it about 6 times and it's worked every time) because it doesn't bleed as much as a cric and it's easier to needle the spot while pushing down on the fat rather than cutting through and hunting for the spot in a bloody cavern. It also has another factor that makes it really attractive in my situation. As I mentioned I don't have ENT. If I cric I'm left with a cric. I have to get someone to come in and change it to a trach and close the cric. After the retrograde I've go an orotracheal intubation and a small hole that doesn't require anything.

 

[bartleby]

If you have a patient in extremis in whom you are considering the administration of epinephrine, you should consider giving it intravenously. IM administration is better than SQ, but you may find yourself in the situation where the delay in absorption between IM/SQ and IV administration is the difference between cutting the person's neck and not.

See this free link from EMRAP (I've got no connection) about making your own epi drip when you don't have 10 minutes to have the RN call the pharmacy.

 

[pseudoknot]

Here's the corrected link from the above post.

 

[Aloha Kid]

Sweet Link. Funny as heck, and I can't get "1ml, 1ml, 1ml" out of my head.

 

[Jeff698]

Strange that this thread came up.

I had about 3 or 4 of these during residency, none where all that severe.

Two shifts ago, I had a patient come in with severe angioedema. He could open his mouth 1 1/2 cm at best. My pucker factor was very high. I odered epi, benadryl, zantac, solumedrol, got my difficult airway box out and called anesthesiology to get some back up.

About that time, EMS calls in. They're enroute with an 80 y/o woman with severe angioedema. Same situation. They're one bed away from each other and about 20 minutes apart.

The ER Gods were smiling on me. Both patients turned around with two doses of epi and everything else I could think to throw at them. No plastic and a complete resolution of symptoms.

Strange timing, indeed.

Take care,
Jeff

 

[DrQuinn]

Strange that this thread came up.

I had about 3 or 4 of these during residency, none where all that severe.

Two shifts ago, I had a patient come in with severe angioedema. He could open his mouth 1 1/2 cm at best. My pucker factor was very high. I odered epi, benadryl, zantac, solumedrol, got my difficult airway box out and called anesthesiology to get some back up.

About that time, EMS calls in. They're enroute with an 80 y/o woman with severe angioedema. Same situation. They're one bed away from each other and about 20 minutes apart.

The ER Gods were smiling on me. Both patients turned around with two doses of epi and everything else I could think to throw at them. No plastic and a complete resolution of symptoms.

Strange timing, indeed.

Take care,
Jeff

Dang dude. Here in DC I have had atleast 4 people (in 26 months) that neee dto be nasally intubated by anesthesia (Just go for the bubbles), and atleast 3 other of my colleagues as well. Granted my patient population is predominantly African American so lots of angio for us.

Q

 

[Jeff698]

Dang dude. Here in DC I have had atleast 4 people (in 26 months) that neee dto be nasally intubated by anesthesia (Just go for the bubbles), and atleast 3 other of my colleagues as well. Granted my patient population is predominantly African American so lots of angio for us.

Q

For some reason, I have a white cloud over my head when it comes to these folks. I guess if you have to get angioedema, try to schedule it when I'm on.

Take care,
Jeff

 

[leviathan]

For some reason, I have a white cloud over my head when it comes to these folks. I guess if you have to get angioedema, try to schedule it when I'm on.

Take care,
Jeff

Make sure you knock on wood! I used to have a great save rate for cardiac arrests, until I started gloating about it. 😳

 

[Jeff698]

Make sure you knock on wood! I used to have a great save rate for cardiac arrests, until I started gloating about it. 😳

Good point. My first 5 codes were all saves. I was quite the stud.

Of course, I was a paramedic for a university EMS system and each of those 5 patients were in their early 20s with witnessed VF arrests.

My next 20 or so had a much more typical result. Strange what happens when your population base changes.

Take care,
Jeff

 

[leviathan]

Good point. My first 5 codes were all saves. I was quite the stud.

Of course, I was a paramedic for a university EMS system and each of those 5 patients were in their early 20s with witnessed VF arrests.

My next 20 or so had a much more typical result. Strange what happens when your population base changes.

Take care,
Jeff

Kinda like my 86 y/o male last weekend. Saw him last month for query CVA (which unfortunately did not go in his favour), and then again on the weekend. His wife is a sweetheart, married for 57 years and had to tell her that unfortunately he was not just having a nap on the couch, and the reason her husband turned pale about an hour ago was because his heart stopped. Where did all the 20 y/o witnessed VF arrests go again? 🙁

 

[DrQuinn]

Weird.

Had another angioedema case.

typical patient, 60ish AAF on ACEI. Was seen at small outside ED, had anesthesia consult who said "patient is unintubatable, she needs to eb transferred." she was transferred with an unstable airway, but we got her in the ED.

WHILE we were scoping her, the SAME hospital in the MICU had a patient get sudden angioedema get a cric and they wanted to transfer that one out. I told them no.

Q