Podcasts · Core EM - Emergency Medicine Podcast
Episode 212: Angioedema
· Episode 212
Episode Episode 212: Angioedema
Angioedema – Recognition and Management in the ED
Hosts: Maria Mulligan-Buckmiller, MD Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Angioedema.mp3
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Show Notes
Definition & Pathophysiology
Angioedema = localized swelling of mucous membranes and subcutaneous tissues due to increased vascular permeability.
Triggers increased vascular permeability → fluid shifts into tissues.
Etiologies
• Histamine-mediated (anaphylaxis)
• Associated with urticaria/hives, pruritus, and redness. • Triggered by allergens (foods, insect stings, medications). • Rapid onset (minutes to hours).
• Bradykinin-mediated
• Hereditary angioedema (HAE): C1 esterase inhibitor deficiency (autosomal dominant). • Acquired angioedema: Associated with B-cell lymphoma, autoimmune disease, MGUS. • Medication-induced: Most commonly ACE inhibitors; rarely ARBs. • Typically lacks urticaria and itching. • Gradual onset, can last days if untreated.
• Idiopathic angioedema
• Unknown cause; diagnosis of exclusion.
Clinical Presentations
• Swelling
• Asymmetric, non-pitting, usually non-painful. • May involve lips, tongue, face, extremities, GI tract.
• Respiratory compromise
• Upper airway swelling → stridor, dyspnea, sensation of throat closure. • Airway obstruction is the most feared complication.
• Abdominal manifestations
• Bowel wall angioedema can mimic acute abdomen:
• Nausea, vomiting, diarrhea, severe pain, increased intra-abdominal pressure, possible ischemia.
Key Differentiating Features
• Histamine-mediated: rapid onset, hives/itching, resolves quickly with epinephrine, antihistamines, and steroids. • Bradykinin-mediated: slower onset, lacks urticaria, prolonged duration, less responsive to standard anaphylaxis medications.
Diagnostic Approach in the ED
• Focus on airway (ABCs) and clinical assessment. • Labs (e.g., C4 level) useful for downstream diagnosis (esp. HAE) but not for acute management. • Imaging: only if symptoms suggest abdominal involvement or to rule out other causes.
Treatment Strategies
• Airway protection is always priority:
• Early consideration of intubation if worsening obstruction or inability to manage secretions.
• Histamine-mediated (anaphylaxis):
• Epinephrine (IM), antihistamines, corticosteroids.
• Bradykinin-mediated:
• Epinephrine may be tried if unclear etiology (no significant harm, lifesaving if histamine-mediated). • Targeted therapies:
• Icatibant: bradykinin receptor antagonist. • Ecallantide: kallikrein inhibitor (less available). • C1 esterase inhibitor concentrate: replenishes deficient protein. • Fresh frozen plasma (FFP): contains C1 esterase inhibitor. • Tranexamic acid (TXA): off-label, less evidence, considered if no other options.
Complications to Watch For
• Airway compromise: rapid deterioration possible. • Abdominal compartment syndrome from bowel edema (rare, surgical emergency).
Take-Home Points
• Secure the airway if in doubt. • Differentiate histamine-mediated vs bradykinin-mediated by presence/absence of hives/itching and speed of onset. • Use epinephrine promptly if suspecting histamine-mediated angioedema or if uncertain. • Consider bradykinin-targeted therapies for confirmed hereditary, acquired, or ACE-inhibitor–related angioedema. • Recognize ACE inhibitors as the most frequent medication trigger; ARBs rarely cause it. • Labs and imaging generally don’t change initial ED management but aid diagnosis for follow-up care.
Read More
Links in the notes 4
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