Evaluation and Management of Angioedema in the Emergency Department

Abstract

Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient’s airway and respiratory status, as well as the sites involved.

Recognition and Differential Diagnosis of Hereditary Angioedema in the Emergency Department

“…Other later generation, oral H 1 antagonists (eg, loratadine, fexofenadine, and cetirizine) can be used in combination with diphenhydramine (1). H 2 blockers such as famotidine or ranitidine can help decrease urticaria (5). Using both H 1 and H 2 blockers may be useful and are appropriate in cases where etiology of the AE is unclear (1).…”

SOP Akutes Angioödem

“…Die Therapie besteht im Absetzen des ACE-Hemmers, allerdings können innerhalb eines Jahres weiterhin Angioödemat-▶ Tab. 2 Charakteristika der verschiedenen Angioödemursachen, adaptiert nach [5,8,11,12]. [7,12].…”

“…In der Notaufnahme kann ▶ Tab. 3 Medikamentöse Akuttherapie des hereditären Angioödems im Erwachsenenalter, adaptiert nach [5,9,11,15]. 4 nur als Reservemedikament zu verwenden, wegen darunter möglicher Zunahme des Angioödems ▶ Tab.…”

“…B. im Rahmen einer ausgeprägten Zungenschwellung, kann eine fiberoptische Wachintubation erforderlich sein. Der Versuch einer konventionellen Atemwegssicherung könnte unter Umständen in einer "Cannot ventilate, cannot intubate"-Situation münden und sollte auch wegen der manipulationsbedingten möglichen Zunahme des Angioödems in Koniotomie-/Tracheotomiebereitschaft durchgeführt werden [5].…”

“…Abklärungsalgorithmus in der Notaufnahme bei Patienten mit akutem Angioödem, adaptiert nach[5,9,10]. Die mit Ziffern markierten Punkte sind im Text erläutert; HAE: hereditary angioedema; AAE: acquired angioedema; C1-INH: C1-Esterase Inhibitor; FFP: fresh frozen plasma; ACE-Hemmer-iAE: ACE-Hemmer-induziertes Angioödem…”