Welcome to EMT City
Register now to gain access to all of our features. Once registered and logged in, you will be able to create topics, post replies to existing topics, give reputation to other members, get your own private messenger, post status updates, manage your profile and so much more. This message will be removed once you have signed in.

ACEi Angioedema

30 posts in this topic

Posted · Report post

[quote name='Asysin2leads' timestamp='1317879861' post='266353']
I think I don't have cojones big enough to suggest a discretionary order of SQ Epi to the tongue to online medical control. But its interesting to know that in high enough doses epinephrine will alleviate bradykinin mediated angioedema.
[/quote]
Yes it would be IM, though check local protocol for acceptable uses. It might be useful to consider a racemic epinephrine SVN as well since the swelling can be in more than just the tongue.
0

Share this post


Link to post
Share on other sites

Posted · Report post

[quote name='Wes' timestamp='1317825547' post='266256']
If I remember correctly, I remember Gene Gandy (some of y'all may know the name) talking once about an ER doc presenting an almost identical case. The ER doc used small doses of Epi 1:1,000 injected directly into the tongue, primarily for the vasoconstrictive effects in an effort to reduce the swelling. Thoughts?
[/quote]

Mr. Gandy is one of my paramedic heroes.
0

Share this post


Link to post
Share on other sites

Posted · Report post

I had a similar case. However, patient was middle aged, awoke in the night to tongue swelling. They complained of tightness to their throat and voice a little hoarse. Only swelling was to the tongue and quite significant. I by no means am aware of ACE inhibitor reactions. Worth researching, however. Patients BP slightly low, PR was within normal limits. No wheezing present.

Per protocol, I chose the allergic reaction route. Started fluids, administered diphenhydramine IV and Sub Q epi. Upon arrival at ER, they continued epi as well as another dose of diphenhydramine, prepared for RSI, and patient was air lifted to a larger facility. Based on their reaction I felt I did well.

Interesting as I kept thinking what this person could have reacted to as they were asleep. Think the call came in midnight or so. I questioned some sort of bite maybe, new medications. I cannot remember the list of meds they were on and did not hear of the patients outcome.
0

Share this post


Link to post
Share on other sites

Posted · Report post

It sounds to me like we have two problems here 1. We have an elderly patient with an allergic reaction and/or possible medication reaction with airway involvement & 2. We have a patient with an extensive cardiac history. If this were my patient I would have given her Oxygen. I would have also given 50mg Benadryl IV, 125mg Solu Medrol IV, plus Tagament or Zantac IV. I would have also considered giving an Albuterol Neb treatment.
0

Share this post


Link to post
Share on other sites

Posted (edited) · Report post

This exact topic was the subject of an edition of [i]Clinical Matters[/i] (the Ambulance Service clinical newsletter)

[quote]

• This is angioedema and [b]not[/b] anaphylaxis.

• Angioedema is isolated swelling of the tongue, mouth or face in the absence of systemic signs of anaphylaxis and in the absence of an identified allergic trigger. We do not know exactly why or how angioedema happens.

• There are hereditary forms of angioedema and acquired forms (most common). Acquired forms are often related to medicines (particularly Angiotensin Converting Enzyme Inhibitors like accupril...

• This is a load and treat en route situation – a very short scene time is expected.

• [An Intensive Care Paramedic (ALS) should] meet you en route.

• Nebulised adrenaline is more likely to be helpful than IM adrenaline. Isolated angioedema rarely responds to IM or IV adrenaline...

• The patient should receive oxygen... this is because he is at high risk of airway obstruction, and if this occurs he will remain adequately oxygenated for much longer if he has been receiving oxygen, than he will if he hasn't been receiving oxygen.

• Often the swelling only involves the tongue – and if you can get behind the tongue then the anatomy is relatively normal. For this reason it is worth trying an LMA or a NPA.

• It is theoretically possible that laryngoscopy and intubation might be successful – but with this severity of tongue swelling that is highly unlikely.

• [b][A patient’s life was recently] saved by an Intensive Care Paramedic performing [cricothyrotomy] on a man with total airway occlusion from angioedema. In this setting the decision to perform cricothyroidotomy must be made before the patient is unsalvageable.[/b]

•[b] With nebulised adrenaline and the passage of time ... he improved [and made a normal recovery][/b].

[/quote] Edited by kiwimedic
0

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now