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Angioedema in the Emergency Department and Reviews the New Higher Level of Care November 2012 Angioedema In The Volume 14, Number 11 Emergency Department: Author R. Gentry Wilkerson, MD, FACEP, FAAEM Assistant Professor, Coordinator for Research, Department of An Evidence-Based Review Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD Abstract Peer Reviewers Alex Manini, MD, MS Assistant Professor of Emergency Medicine, Mount Sinai School of Angioedema is the end result of a variety of pathophysiological Medicine, New York, NY processes resulting in transient, localized, nonpitting swelling James Scott, MD Professor of Emergency Medicine and Health Policy, The George of the subcutaneous layer of the skin or submucosal layer of the Washington University of Medicine and Health Sciences, Washington, DC respiratory or gastrointestinal tracts. It is now generally accepted that the swelling is mediated by either histamine or bradykinin. CME Objectives Angioedema may result in severe upper airway compromise Upon completion of this article, you should be able to: 1. Discuss the various types of angioedema and the mechanism by or—less commonly recognized—compromise in the gastrointes- which the swelling occurs. tinal tract often associated with severe abdominal pain. A variety 2. Describe an appropriate workup of a patient with undifferentiated of new therapeutic options are becoming available for use in the angioedema. United States that have the potential to greatly impact the manage- 3. Determine appropriate therapy for treatment of angioedema and understand the rationale behind each therapeutic option. ment and outcomes for those with severe clinical manifestations. 4. Discuss appropriate disposition for these patients with an This review assesses the evidence on the causes and treatments of understanding of which patients are at higher risk of needing a angioedema in the emergency department and reviews the new higher level of care. therapeutic options available for treatment of angioedema based Date of original release: November 1, 2012 Date of most recent review: October 10, 2012 on their effectiveness, price, and availability. Termination date: November 1, 2015 Medium: Print and Online Method of participation: Print or online answer form and evaluation Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-in-Chief Medical Center, University of North Charles V. Pollack, Jr., MA, MD, Stephen H. Thomas, MD, MPH International Editors Carolina School of Medicine, Chapel FACEP George Kaiser Family Foundation Andy Jagoda, MD, FACEP Peter Cameron, MD Hill, NC Chairman, Department of Emergency Professor & Chair, Department of Professor and Chair, Department of Academic Director, The Alfred Medicine, Pennsylvania Hospital, Emergency Medicine, University of Emergency Medicine, Mount Sinai Steven A. Godwin, MD, FACEP Emergency and Trauma Centre, School of Medicine; Medical Director, University of Pennsylvania Health Oklahoma School of Community Professor and Chair, Department Monash University, Melbourne, Mount Sinai Hospital, New York, NY System, Philadelphia, PA Medicine, Tulsa, OK of Emergency Medicine, Assistant Australia Editorial Board Dean, Simulation Education, Michael S. Radeos, MD, MPH Jenny Walker, MD, MPH, MSW University of Florida COM- Assistant Professor of Emergency Assistant Professor, Departments of Giorgio Carbone, MD William J. Brady, MD Jacksonville, Jacksonville, FL Medicine, Weill Medical College Preventive Medicine, Pediatrics, and Chief, Department of Emergency Professor of Emergency Medicine, of Cornell University, New York; Medicine Course Director, Mount Medicine Ospedale Gradenigo, Chair, Resuscitation Committee, Gregory L. Henry, MD, FACEP Research Director, Department of Sinai Medical Center, New York, NY Torino, Italy University of Virginia Health System, CEO, Medical Practice Risk Emergency Medicine, New York Charlottesville, VA Assessment, Inc.; Clinical Professor Ron M. Walls, MD Amin Antoine Kazzi, MD, FAAEM Hospital Queens, Flushing, New York of Emergency Medicine, University of Professor and Chair, Department of Associate Professor and Vice Chair, Peter DeBlieux, MD Michigan, Ann Arbor, MI Robert L. Rogers, MD, FACEP, Emergency Medicine, Brigham and Department of Emergency Medicine, Louisiana State University Health FAAEM, FACP Women’s Hospital, Harvard Medical University of California, Irvine; Science Center Professor of Clinical John M. Howell, MD, FACEP Assistant Professor of Emergency School, Boston, MA American University, Beirut, Lebanon Medicine, LSUHSC Interim Public Clinical Professor of Emergency Medicine, The University of Hospital Director of Emergency Medicine, George Washington Scott Weingart, MD, FACEP Hugo Peralta, MD Maryland School of Medicine, Medicine Services, LSUHSC University, Washington, DC; Director Associate Professor of Emergency Chair of Emergency Services, Baltimore, MD Emergency Medicine Director of of Academic Affairs, Best Practices, Medicine, Mount Sinai School of Hospital Italiano, Buenos Aires, Faculty and Resident Development Inc, Inova Fairfax Hospital, Falls Alfred Sacchetti, MD, FACEP Medicine; Director of Emergency Argentina Church, VA Assistant Clinical Professor, Critical Care, Elmhurst Hospital Francis M. Fesmire, MD, FACEP Dhanadol Rojanasarntikul, MD Department of Emergency Medicine, Center, New York, NY Professor and Director of Clinical Shkelzen Hoxhaj, MD, MPH, MBA Attending Physician, Emergency Thomas Jefferson University, Research, Department of Emergency Chief of Emergency Medicine, Baylor Medicine, King Chulalongkorn Philadelphia, PA Senior Research Editor Medicine, UT College of Medicine, College of Medicine, Houston, TX Memorial Hospital, Thai Red Cross, Joseph D. Toscano, MD Chattanooga; Director of Chest Pain Scott Silvers, MD, FACEP Thailand; Faculty of Medicine, Eric Legome, MD Emergency Physician, Department Center, Erlanger Medical Center, Chair, Department of Emergency Chulalongkorn University, Thailand Chief of Emergency Medicine, of Emergency Medicine, San Ramon Chattanooga, TN Medicine, Mayo Clinic, Jacksonville, FL King’s County Hospital; Professor of Regional Medical Center, San Suzanne Peeters, MD Nicholas Genes, MD, PhD Clinical Emergency Medicine, SUNY Corey M. Slovis, MD, FACP, FACEP Ramon, CA Emergency Medicine Residency Assistant Professor, Department of Downstate College of Medicine, Professor and Chair, Department Director, Haga Hospital, The Hague, Emergency Medicine, Mount Sinai Brooklyn, NY of Emergency Medicine, Vanderbilt Research Editor The Netherlands School of Medicine, New York, NY Keith A. Marill, MD University Medical Center; Medical Matt Friedman, MD Assistant Professor, Harvard Medical Director, Nashville Fire Department and Emergency Medical Services Fellow, Michael A. Gibbs, MD, FACEP School; Emergency Department International Airport, Nashville, TN Fire Department of New York, New Professor and Chair, Department Attending Physician, Massachusetts York, NY of Emergency Medicine, Carolinas General Hospital, Boston, MA Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Manini, Dr. Scott, Dr. Jagoda, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. The following disclosure of relevant financial interest with a potentially financially interested entity was made: Dr. Wilkerson reported that he had received research support from Dyax, Corp.Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support. Case Presentations You ask yourself several questions: • What is the cause of her recurrent abdominal pain? In the middle of an unusually slow evening shift, a • Does she need an abdominal CT scan, and, if yes, 52-year-old black male presents to the ED from walk-in does it need to be with contrast? triage with a complaint of lip swelling. He states that he • Does she need emergent surgical consultation? noticed a tingling in his lips shortly after waking that • Other than treating the pain, is there any medication morning, but it wasn’t until he brushed his teeth that that is indicated? he noticed how large his lips had become. He decided to come to the hospital almost 12 hours later only after Introduction family members insisted that he get “checked out.” He denies any recent trauma, infection, or known exposures Angioedema is the clinical manifestation of tran- to possible allergens. He denies any pain or itching. His sient, localized, nonpitting swelling of the subcuta- past medical history is significant for hypertension and neous layer of the skin or submucosal layer of the borderline diabetes. He is unable to remember the name respiratory or gastrointestinal tracts. The first widely of the medication that he takes for his blood pressure, but recognized description of angioedema was by Hein- he says he has been taking it for years. His vital signs are: rich Quincke in 1882. In honor of his contribution, it heart rate, 74 beats per minute; blood pressure, 156/82 is sometimes referred to as Quincke edema. mm Hg; respiratory rate, 16 breaths per minute; tempera- Angioedema is not a disease; rather, it is a physi- ture, 36.8°C; and oxygen saturation, 98% on room air. He cal manifestation of a variety of pathophysiological is comfortable and in no apparent distress. It would be im- processes. These processes have the end result of possible to miss the rather impressive size of
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