points from case ? when to give epi pen to patients with allergic rxn’s/ angioedema ...
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Case
Points from case ? When to give Epi pen to patients with
allergic Rxn’s/ angioedema Documentation ( how to RTN to ER ?) Admission criteria for allergic Rxn’s ( wouldn’t
help with this case) Beware bowel edema as manifestation of
allergic Rxn Earlier airway intervention
?surgical
Angioedema
Angioedema is characterized by painless, nonpruritic, nonpitting, and well-circumscribed areas of edema due to increased vascular permeability
Angioedema- Location
most apparent in the head and neck, including the face, lips, floor of the mouth, tongue, and larynx, but edema may involve any portion of the body
may involve the gastrointestinal tract, leading to intestinal wall edema
Angioedema- Pathophysiology
This deficiency in functioning C1-INH leads to autoactivation of the complement system and release of kininlike mediators, resulting in edema of the subcutaneous or submucosal tissues
C’ Pathway (-) C1-INH(-)
kallikreinhigh molecular weight–kinogen bradykinin
Angioedema - Classification
1) Hereditary angioedema (HAE) 2) Acquired angioedema (AAE) 3) Angioedema associated with allergic
reactions (which is often associated with urticaria)
4) Angioedema secondary to medications ACE / ARB
5) Idiopathic angioedema
Angioedema- HAE
C1 Esterase Inhibitor Deficiency
3 Types 1) Low levels of C1-INH (80-85%) 2) Normal Levels but dysfunctional 3) Normal levels and function – only women?
X-linked dominant inheritance
Angioedema
Precipitants of HAE angioedema Mental and physical stress Trauma Dental or surgical procedures Infections Menstruation Pregnancy Oral contraceptives containing estrogens
HAE- Treatment
Epinephrine, corticosteroids, and antihistamines are NOT effective in patients with HAE, AAE, and ACE inhibitor–induced angioedema.
These agents are recommended as second-line therapy. (in cases of angioedema due to allergic causes, these medications are first-line therapies.)
HAE - Treatment
1st line treatment Vapor-heated C1-INH concentrate
(500-2000U IV) FFP ( may worsen attack?)
2U IV Other
tranexamic acid epsilon-aminocaproic acid( inhibit plasmin – plays role in initiating C’
cascade)
Angioedema - Classification
1) Hereditary angioedema (HAE) 2) Acquired angioedema (AAE) 3) Angioedema associated with allergic
reactions (which is often associated with urticaria)
4) Angioedema secondary to medications ACE / ARB
5) Idiopathic angioedema
Angioedema - Classification
1) Hereditary angioedema (HAE) 2) Acquired angioedema (AAE) 3) Angioedema associated with allergic
reactions (which is often associated with urticaria)
4) Angioedema secondary to medications ACE / ARB
5) Idiopathic angioedema
Angioedema – Allergy Induced
Allergy-induced angioedema an IgE-mediated hypersensitivity reaction
Causes Medications Food Environmental allergens (insect bites)
Anaphylaxis – Drug Therapy
Vasopressin ( Level C) 4U bolus 10U diluted in 10mls ( titrate to effect)
Surviving Sepsis Campaign guidelines Recommend an AVP dosage of 0.03– 0.04
IU/min, a recent study suggested that 0.067 IU/min
(4 IU/h)
Angioedema - Classification
1) Hereditary angioedema (HAE) 2) Acquired angioedema (AAE) 3) Angioedema associated with allergic
reactions (which is often associated with urticaria)
4) Angioedema secondary to medications ACE / ARB
5) Idiopathic angioedema
Angioedema
0.1-0.2% of patients treated with ACE inhibitors develop angioedema
Idiosyncratic Rxn 14 fold increased risk in first month of
treatment Has occurred >1 yr after initiation
Angioedema- Emerg Facts
94% of angioedemas in ED due to meds Most of these due to ACE Inhibitors As many as 22 % require intubation 11% mortality ARB’s also cause but incidence unknown
(case reports) Mainly losarten
Angioedema- Predictors
Airway Intervention (Zirkle et al 2000) Increasing age Symptoms ( eg. stridor, hoarseness, dyspnea)
Not correlated Rapidity of onset of sx Cause of angioedema Gender Previous history
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