You are called to see a 37 year old obese female in the PCU who is having acute resp. distress.
She was admitted for acute angioedema in the ED 2 hours ago. She was given racemic epi, steroids
and antihistamines and was ok but precipitously worsened suddenly in the last 10 minutes.
Saturations are around 88% on high flow cannula @ 15 L. RR is about 35. She has significant
facial, lip, periorbital and laryngeal edema. What is your next step?
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Thursday, May 24, 2018
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This patient appears to be in considerable respiratory distress as noted by her tachypnea and diminished oxygenation. The concern here is that the worsening edema can cause airway compromise, so the next step would be intubation using awake fiberoptic intubation. This is a delicate procedure because any manipulation of the airway can cause the swelling to worsen and the intubation should therefore be performed by an expert only. Preparations should be made for an emergent surgical airway as well. If intubation is unsuccessful the likelihood is that the patient will be in even more respiratory distress.
ReplyDeleteThe medical treatment started, steroids, antihistamines and epinephrine are the correct treatment for mast cell medicated angioedema. For angioedema that is propagated by other factors there are several other treatment options. If bradykinin is the primary instigator such as in the case of ACE inhibitor related angioedema there is a roll for fresh frozen plasma because it contains ACE which will help degrade the bradykinin. Another option is C1-Esterase inhibitors. For hereditary angioedema options include icatibant (a bradykinin antagonist), ecallantide (inhibits a precursor of bradykinin formation) and C1 esterase inhibitors.
https://lifeinthefastlane.com/ccc/angioedema/
https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/angioedema
uptodate
dynamed
the patient would need to be intubated due to airway compromise.
ReplyDeletehttps://resident360.nejm.org/pages/home?resource_collection_id=critical-care&subtopic=ventilation&subgroup=fast-facts
Afterwards you would need to treat the underlying condition to get resolution of symptoms.
Uptodate: an overview of angioedema
Would order intramuscular epi stat and immediately call for anesthesia and contact ENT in anticipation for a difficult intubation. Would also transfer the patient to the unit as soon as possible. Would hold off any suspected external causes and once the patient is intubated would investigate further to find out the cause of the angioedema for a targetted treatment. Would provide IV solumedrol, IV ranitidine and IV benadryl. Would put on continuous pulseox and closely monitor O2 saturation on the vent and cardiac rythm.
ReplyDeleteBased on the patient condition, having worsening laryngeal edema, I will try to secure the airway . I will manage the patient with intramuscular epinephrine, IV steroids , IV ranitidine and emergently call anesthesia and ENT and I think in that case the intubation will be very difficult because of rapid onset and progression of laryngeal edema so possible Tracheotomy instead of intubation.
ReplyDeleteThis patient needs emergent intubation. She would be a difficult airway due to facial edema and obesity. Fiberoptic intubation or video laryngoscopy would be the 2 best options.
ReplyDeleteThis is the nightmare case that nobody ever wants to see. For other Marvel Cinematic universe geeks like me, as Thanos would say, "Dread it, Run from it, Destiny arrives all the same." We hope to never see this case but eventually, we all do. It is a no brainer that this patient needs to be intubated. The question is how you do it safely without the patient asphyxiating in front of your eyes while your help closely trying to back them. Fiberoptic intubation is always a reasonable starting point. But I would venture that the great majority of you, myself included, cannot proficiently fiberopticly intubate a morbidly obese patient. Chances are most hospitals to go to will not even have the equipment available to you. Attempting direct laryngoscopy in this patient is suicide. Well its homicide to the patient, suicide to your career. Video laryngoscopy is also ill advised without immediate surgical backup available at bedside. The most important concept in this case for managing the airway of the patient like this is knowing when to call for help. Without question the 1st call as to anesthesia and surgery whether that General surgery or ENT. Do not attempt to intubate this patient without a surgeon and a emergency tracheostomy/cricothyroidotomy kit next to you. You will need all hands on deck for this airway. If the patient is able to maintain saturations for the moment on high-flow and/or BiPAP, try to get them down to the intensive care unit or if possible even the operating room so you can have the most controlled environment possible. You have anesthesia present with a video laryngoscope. You have a difficult airway kit with a bougie available. You have the aforementioned cric and trach kits at bedside along with the surgeon. At that point, we gently attempt awake intubation with something like ketamine which will not blunt the respiratory drive and see if we can visualize the epiglotis and cords. if so, proceed with ETT. If we cannot see the cords it VL, fiberoptic (if available) is another option again with something like ketamine or a little versed to sedate. A core concept is you do not want to give an induction agent or paralytic or anything that will kill the patient's inability to breathe spontaneously until you are sure you have the ability to cannulate there airway. This patient's saturations are 88% on 15 L. She is maintaining. Her situation is urgent/emergent and need to be dealt with acutely but she is breathing and maintaining saturations. Giving her a full induction agent or a paralytic will kill the 1 good thing she has going for her. Visualization needs to be achieved prior to induction and if it does not appear to be the case, directly proceeding to emergent trachestomy is the recommendation.
ReplyDeleteTake away points.
Know when to call for help.
Remain calm and assess the situation and have all options for all possible scenarios available at bedside with appropriate staff.