Question on a call

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Cawolf86

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Hey there, not a scenario really but just wondering what route you would take a pretty basic run I had yesterday.

ALS and a BLS ambulance dispatched at 1200 to a private clinic for a c/c of SOB. We arrived to find a 35 y/o female sitting alert in an exam chair in mild distress. She states that last night she felt sick and had a sore throat so she gargles salt water and drank tea to no relief. When she woke up this morning at 0800 she felt her throat swelling and went to a private clinic. She states this has never happened before.

C/C - Left neck, ear, and jaw pain with "a lump in her throat"
Alert and Oriented with a GCS of 15

Hx - HTN
A - None
M - Lisinopril started 3 months ago. States she takes each morning but did not take it today due to her distress.

The facility has started a 20G in the hand and has NS running wide open (??) and has her placed on a NC at 4lpm.

V/S - BP of 175/110, P of 110 and reg, Resp of 20 with good volume, sP02 100% on 4lpm, and Sinus Tach with no ectopy. Skins are normal, warm, and dry.

Lungs are clear bilateral with good air movement though there is noticable hoarseness when she speaks and feels "a lump in her throat".

There is swelling to the left anterior/lateral neck, swelling of the left side of her jaw, and possible swollen lips. There are no hives, rashes, wheals, and no sensation of itching, tingling, tightness. The tongue appears normal and not enlarged.

She states she has not taken any new meds, no stings, no bites, no animals, no new foods.

Transport time is approx 10 minutes.

So my question is what route of treatment do you take here? Do you treat? Transport ALS or BLS?

After a few replies I can post what we went with and the Dx from the MD.

Thanks!
 
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There's any number of things it could be. ACE inhibitor induced angioedema springs to mind. Drive to hospital.
 
Does angioedema present unilaterally though? The times I have seen severe facial swelling it included the tongue, orbits, and hands - and was evenly spread. I will say I am inexperienced and that is a good thought. So would you treat if you suspected a progressive swelling (even if stable)?
 
Cawolf86 said:
Does angioedema present unilaterally though? The times I have seen severe facial swelling it included the tongue, orbits, and hands - and was evenly spread. I will say I am inexperienced and that is a good thought. So would you treat if you suspected a progressive swelling (even if stable)?
Click to expand...

IF it is ACE inhibitor angioedema as opposed to angioedema from say, anaphylaxis, then yes it is quite commonly unilateral. It's very hard when I can't assess a patient myself to work out a likely diagnosis though. There are many, many things that could cause these symptoms.

Not much we can do about it at the moment. I would not hand this off to BLS, but nor would I wait around for ALS to arrive given the short transport time.
 
In this case we were a transporting ALS unit dispatched with a transporting BLS unit as well.
 
Brown was going to say ACE inhibitor induced angioedema

Send the IC car back home (Smash needs his rest!) and drive to hospital
 
See you learn every day - would there be any response from an antihistamine in this case?
 
I would also be concerned about some sort of abcess.
 
Aidey said:
I would also be concerned about some sort of abcess.
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Indeed, and the pain associated with her condition would add weight to this - angioedema is normally painless. ACEI angioedema was just a SWAG when I saw the lisinopril. Was she African American? ACEI angioedema seems to be more common in htis population.

Antihistamines would not be of any use. ACEI angioedema seems to be related to the breakdown of bradykinins: ACEIs stop the breakdown, although the exact mechanism is unclear. It is probably also bradykinin that is responsible for the cough associated with ACEIs.

Sometimes epi may help, there may be a role for steroids, but I'm not sure of the effectiveness of either intervention.

What was the diagnosis?
 
I was also gonna go with some sort of abcess. Given all the assessment findings provided and 10min ETA to the hospital, no stridor, 100% on minimal O2, I would turf to BLS most likely but would really have to physically see the patient.
 
With "noticeable hoarseness" I would not be "turfing" this to BLS. I'm not a fan of airway compromise, but maybe I am a bit old fashioned.
 
Smash said:
With "noticeable hoarseness" I would not be "turfing" this to BLS. I'm not a fan of airway compromise, but maybe I am a bit old fashioned.
Click to expand...

Old fashioned? As far as Brown is concerned its still 1990 and Advanced Care Officer with a Lifepak 10 and nasotracheal intubation is all the rage as career progression!

Brown thinks its angiodeema.
 
I would give back my piece of **** Philips MRx for a LP10 in a heartbeat!
 
I wouldn't be turfing this patient either with the info given so far. If it is an abcess things can go down hill fast if it ruptures.
 
Ludwig's Angina? I've only seen it once, and that was on a transfer, so I'm just throwing it out there to add to the list.....

If it is ACEI induced angioedema, from everything I've read, if they decompensate, nothing except airway management will help, and they may need a surgical airway. This is something I would not turf to BLS, and I wouldn't sit around too long.....
 
Sorry for that delay - was out seeing Rango.

She was indeed African American - making the ACEI angioedema possible as was said.

There was no fever or signs of localized or systemic infectious processes.

The diagnosis was an abscess that was on the left neck just inferior to the jaw line. The patient was given 50mg Diphenhydramine per base orders due to the swelling. She was taken by ALS due to the upper airway restriction as evidenced by the hoarseness.

I did not realize that an abscess could be unstable to the point of rupture though. is there any other pertinent info on this call that I could have obtained to determine the stability or cause of the swelling?
 
Like I said in my previous post I would obviously want to see the pt. before turfing to BLS :rolleyes: and hear this "hoarseness" that was described. When I think hoarse I think sore throat etc. I get hoarse with strep throat for example but I don't have airway compromise. Stridor on the other hand I would be concerned about.
 
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