In the ED, their vitals/exam are as above. The etiology of this patient’s angioedema is likely ACE-inhibitor/ARB mediated but other bradykinin-mediated (hereditary) angioedema and histamine-induced angioedema are on the differential. With*** current imminent airway compromise as patient with*** stridor, with*** tachypnea, and with*** change in O2 saturation. Hence, will proceed as below.
– Labs/Tests: CBC, CMP, ESR, CRP, Tryptase, PT/INR, Type & Screen, COVID-19 RT PCR, Bedside nasopharyngoscopy with loaded 6.5mm ETT and suction. Consider sending ANA, C1, C1 inhibitor (functional & antigen), C3, C4, and tryptase if admitting to hospital.
– Imaging: None
– Treatments:
— IM epi/IV H1 blocker/IV H2 blocker/IV solumedrol already given
— Low threshold antiemetics as needed for symptoms
— Consider TXA 1g +/- FFP 2u +/- C1 esterase inhibitor (Berinert 20 units/kg vs. Cinryze 1000 units) +/- Bradykinin B2 receptor antagonist (Icatibant & Ecallantide) if thought to be bradykinin mediated
— Given patient has significant angioedema and is awake without altered mental status (and hence able to maintain respiratory drive), low threshold for awake fiberoptic intubation (pretreatment w/ glycopyrrolate 0.2mg IV/zofran/afrin/aerosolized 4% lidocaine (5mL at 5L/min), ketamine 1.5mg/kg IV for sedation, visualize cords w/ suction PRN, anesthetize cords, advance lubricated 6.5mm ETT, propofol gtt)
— If the above fails, prepare for ketamine-dissociated cricothyrotomy
– Consults: ENT, Low threshold for anesthesia consultation
– Dispo: Admit to SICU