points from case ? when to give epi pen to patients with allergic rxn’s/ angioedema ...

CASE PRESENTATION

Case

Points from case ? When to give Epi pen to patients with

allergic Rxn’s/ angioedema Documentation ( how to RTN to ER ?) Admission criteria for allergic Rxn’s ( wouldn’t

help with this case) Beware bowel edema as manifestation of

allergic Rxn Earlier airway intervention

?surgical

Intubate That!!!

Angioedema

Angioedema is characterized by painless, nonpruritic, nonpitting, and well-circumscribed areas of edema due to increased vascular permeability

Angioedema- Location

most apparent in the head and neck, including the face, lips, floor of the mouth, tongue, and larynx, but edema may involve any portion of the body

may involve the gastrointestinal tract, leading to intestinal wall edema

Angioedema

Angioedema- Pathophysiology

This deficiency in functioning C1-INH leads to autoactivation of the complement system and release of kininlike mediators, resulting in edema of the subcutaneous or submucosal tissues

C’ Pathway (-) C1-INH(-)

kallikreinhigh molecular weight–kinogen bradykinin

Angioedema - Classification

1) Hereditary angioedema (HAE) 2) Acquired angioedema (AAE) 3) Angioedema associated with allergic

reactions (which is often associated with urticaria)

4) Angioedema secondary to medications ACE / ARB

5) Idiopathic angioedema

Angioedema- HAE

C1 Esterase Inhibitor Deficiency

3 Types 1) Low levels of C1-INH (80-85%) 2) Normal Levels but dysfunctional 3) Normal levels and function – only women?

X-linked dominant inheritance

Angioedema

Precipitants of HAE angioedema Mental and physical stress Trauma Dental or surgical procedures Infections Menstruation Pregnancy Oral contraceptives containing estrogens

HAE- Treatment

Epinephrine, corticosteroids, and antihistamines are NOT effective in patients with HAE, AAE, and ACE inhibitor–induced angioedema.

These agents are recommended as second-line therapy. (in cases of angioedema due to allergic causes, these medications are first-line therapies.)

HAE - Treatment

1st line treatment Vapor-heated C1-INH concentrate

(500-2000U IV) FFP ( may worsen attack?)

2U IV Other

tranexamic acid epsilon-aminocaproic acid( inhibit plasmin – plays role in initiating C’

cascade)

Angioedema- AAE

Rare Type I – lymphomas / lymphoproliferative dz Type II - autoantibodies ? cause

Angioedema – Allergy Induced

Allergy-induced angioedema an IgE-mediated hypersensitivity reaction

Causes Medications Food Environmental allergens (insect bites)

Angioedema – Anaphylaxis / Treatment(Level of Evidence)

Angioedema – Anaphylaxis / Treatment

(Level of Evidence)

Anaphylaxis – Drug Therapy

Vasopressin ( Level C) 4U bolus 10U diluted in 10mls ( titrate to effect)

Surviving Sepsis Campaign guidelines Recommend an AVP dosage of 0.03– 0.04

IU/min, a recent study suggested that 0.067 IU/min

(4 IU/h)

Angioedema- ACE Inhibitors

Angioedema

0.1-0.2% of patients treated with ACE inhibitors develop angioedema

Idiosyncratic Rxn 14 fold increased risk in first month of

treatment Has occurred >1 yr after initiation

Angioedema- Emerg Facts

94% of angioedemas in ED due to meds Most of these due to ACE Inhibitors As many as 22 % require intubation 11% mortality ARB’s also cause but incidence unknown

(case reports) Mainly losarten

Angioedema- Predictors

Airway Intervention (Zirkle et al 2000) Increasing age Symptoms ( eg. stridor, hoarseness, dyspnea)

Not correlated Rapidity of onset of sx Cause of angioedema Gender Previous history

Angioedema- Airway

Preferred techniques Awake nasotracheal ( orotracheal ) Cricothyrotomy Tracheostomy

points from case ? when to give epi pen to patients with allergic rxn’s/ angioedema ...

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