# Unknown medical



## zzyzx (Oct 7, 2015)

You respond to a 65 y/o female who opens the door. The first thing you notice is the pronounced swelling of her lower lip. She appears very anxious and you can barely understand her due to her speech being slurred. She is pointing to her lip and you can understand that she is also complaning of a "sore throat." No know allergies and no new medications. No lower leg edema. 

RR 24. Lung sounds clear bilaterally 
Pulse 110. ST on 3-lead
Hx. DM, HTN, MI, hypothyroidism,
Meds. Metformin, lisinopril, synthroid, Wellbutrin, aspirin


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## chaz90 (Oct 7, 2015)

Tracheal sounds? Any increasing shortness of breath? How about swelling of the tongue or other structures in the mouth? Urticaria present anywhere? Itching? 

Can we get an SpO2 reading and BP?

How long has she been taking the lisinopril, and what was the timeframe for the onset of these symptoms? Recent fever?


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## NomadicMedic (Oct 7, 2015)

High index of suspicion of ACE Inhibitor angioedema.


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## zzyzx (Oct 7, 2015)

chaz90 said:


> Tracheal sounds? Any increasing shortness of breath? How about swelling of the tongue or other structures in the mouth? Urticaria present anywhere? Itching?
> 
> Can we get an SpO2 reading and BP?
> 
> How long has she been taking the lisinopril, and what was the timeframe for the onset of these symptoms? Recent fever?



BP 175/90. SpO2 99% No fever. Taking lisinopril for weeks. No other apparent swelling. No hives. Pt c/o SOB and is anxious and tachypneic but without labored breathing and has no stridor. 

Treatment?


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## chaz90 (Oct 7, 2015)

Hmm. There's not a lot of support for the efficacy of antihistamines and steroids in these patients if she truly is suffering from angiotensin induced angioedema. I'd probably consult with medical control as I set up for airway management regarding their thoughts on IV Benadryl, but I'm not optimistic. 

Really, the next step depends on how bad this swelling is and if it is getting worse. Despite not having labored breathing or being hypoxic yet, the risk of airway obstruction is real if this swelling continues, and at that point further airway management is going to be a nightmare. 

I'm reluctant to take away her airway, but if it's continuing to swell along with already being SOB, I'm even more reluctant to let it get worse and swell completely shut during my transport (particularly if it is as long as many of my transports are). With that in mind, what kind of airway assessment do we have? Mallampati score, 3-3-2 scoring, neck flexion? Obstruction is obviously considered a strong possibility. 

If I think I can successfully ventilate this patient and intubate her despite her swelling, RSI. High flow NC on during intubation to slow desaturation, and several smaller than expected necessary ET tubes at the ready. Bougie on first attempt. Cric kit at the ready next to me to ward off the full obstruction airway demons.


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## Tigger (Oct 8, 2015)

chaz90 said:


> Hmm. There's not a lot of support for the efficacy of antihistamines and steroids in these patients if she truly is suffering from angiotensin induced angioedema. I'd probably consult with medical control as I set up for airway management regarding their thoughts on IV Benadryl, but I'm not optimistic.


My understanding is that none of the typical therapies will have any effect on angioedema here as ACE inhibitor angioedma is not caused by allergens. This renders steroids, anti-histamines, and epi all ineffective. I recently learned in the ED that fresh frozen plasma may have a role in treatment. Rather than butcher that mechanism, look here.

Would a nasal intubation attempt be viable?


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## DesertMedic66 (Oct 8, 2015)

I would not like to get one of these patients in my local system. No RSI. No nasal intubation. No crics. Code 3 to the closest facility


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## EMT11KDL (Oct 8, 2015)

Tigger i Saw that article awhile back, someone else posted it on i think facebook, but it was nice to review and see it again.


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## Carlos Danger (Oct 8, 2015)

It sure sounds like ACEI angioedema, but unless you can prove it isn't a histamine mediated reaction, I would proceed with anaphylaxis treatment. Low risk, potentially helpful.

Here's the thing about intubating this patient: it is going to be very hard, and likely bloody. From the description provided, she's already past that point. However, most of these cases don't progress beyond the point she's at now, fortunately - few of these patients require intubation.

I would give some benadryl, pepcid, solu-medrol, robinul or atropine, and humidified oxygen via NC, and not touch her airway unless she develops stridor or increased WOB. Then take a ride to a hospital that can get anesthesia (and preferably ENT) on deck.


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## Ewok Jerky (Oct 8, 2015)

Tigger said:


> Rather than butcher that mechanism, look here.


As we all know ACE metabolizes bradykinin, and ACEi result in a buildup of bradykinin, which causes vasodilation and likely plays a role in angioedema. FFP contains uninhibited ACE which will metabolize bradykinin.

On another note, I completely agree with @Remi , great for anaphylaxis and don't touch the airway unless you have to, most angioedema resolved without death.


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## chaz90 (Oct 8, 2015)

Fair point about treating the potential for allergic reaction as it is low risk and high reward. 

How much of a risk is there of increasing swelling past this point? I was, perhaps mistakenly, under the impression that most of these patients ended up intubated until swelling resolved. 

I would just be very apprehensive of taking a conservative approach only to find I had waited too long to act when I finally pulled the trigger. Waiting until increased work of breathing and stridor presents sounds like the inevitable intubation at that point will only be more difficult...


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## phideux (Oct 9, 2015)

Definitely sounds like a good case of Lisinopril face, seen it a bunch of times in the ER, I think the majority of our county is overweight, hypertensive and on Lisinopril. Rarely does it involve the airway. Usually benadryl/steroids and observation until the swelling starts going down.


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## Carlos Danger (Oct 9, 2015)

chaz90 said:


> How much of a risk is there of increasing swelling past this point? I was, perhaps mistakenly, under the impression that most of these patients ended up intubated until swelling resolved.
> 
> I would just be very apprehensive of taking a conservative approach only to find I had waited too long to act when I finally pulled the trigger. Waiting until increased work of breathing and stridor presents sounds like the inevitable intubation at that point will only be more difficult...



My understanding is that relatively few patients who present with ACEI angioedema end up intubated. Obviously it is difficult or impossible to predict any individual patient's future course and you have to just go with your gut, but most just develop some swelling that can be uncomfortable and distressing, but which rarely progresses to cause airway obstruction. That said, I've only encountered one of these in my career, so I'm no expert. I'd be interested in hearing @ERDoc's comments on this.

My point about the airway is that even with moderate  lip and tongue (and presumably, other pharyngeal structures) edema and increased friability, even a moderate case could already be a nightmare airway. Personally that's something I'd rather not deal with in the the field in a patient who is currently not in respiratory distress and in whom statistically, won't be at any point. Same approach as epiglottitis - don't mess with it unless you have to, or have the right tools - flexible fiberoptics - and a surgeon standing by.

If they do progress, then a crich would be my approach in the field.


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## zzyzx (Oct 9, 2015)

Yes, this was ACE inhibitor induced angioedema. It only took 12 minutes for someone (DE Medic) to figure this out! 
It's the second time I've seen it, and both times the swelling was isolated to their lower lip. Both patients had also been on an ACE inhibitor for a long time prior to this happening.


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## Gurby (Oct 10, 2015)

zzyzx said:


> Both patients had also been on an ACE inhibitor for a long time prior to this happening.



Very good to know - I was under the impression that it was usually only found in people who had started it relatively recently.


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## ERDoc (Oct 11, 2015)

Most cases of ACEI angioedema do not progress to the point of intubation (thankfully).  I have never had to intubate one.  As others have said, the standard anaphylaxis treatment is pretty useless but will almost always be given, especially in severe cases.  This is probably for 2 reasons, just in case it is not ACEI angio and so that we can feel like we are doing something.  It can start any time after ACEIs are started, even years later.


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