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Non-Cardiac Chest 2/16/2019 Non-Cardiac Chest Therese Mead, DO, RDMS, FACEP Associate Program Director Central Michigan University EM Residency 1 2 3 4 5 6 1 2/16/2019 A 82 year old female awoke with lip swelling 1 hour ago. On arrival to the ED, she is awake, alert, able to speak and Which part of the body can be affected by angioedema? complains of a slight pressure in her throat. A. Lips BP: 220/110, HR 55, RR 22, T 36 C and SPO2 is 98% on room air. B. Extremities C. Genitalia On physical examination, the patient is sitting upright, slightly D. Tongue anxious, with lip swelling, neck edema, and tongue slightly E. All of the Above protruding. 7 8 9 Angioedema Clinical Presentation Which part of the body can be affected by angioedema? A. Lips B. Extremities The lips, face, tongue, neck, extremities and/or genitalia can all be affected by angioedema C. Genitalia D. Tongue E. All of the Above 10 11 12 2 2/16/2019 Angioedema Pathophysiology True or False: Angioedema is always an IgE mediated True or False: Angioedema is always an IgE mediated allergic reaction to a stimulus allergic reaction to a stimulus Angioedema is not always an IgE mediated allergic reaction to a stimulus 13 14 15 Angioedema Clinical Presentation This patient’s presentation is consistent with which of these This patient’s presentation is consistent with which of these conditions? conditions? The etiologies of angioedema (a symptom), include: A. Hereditary Angioedema (HAE) A. Hereditary Angioedema (HAE) ✓Hereditary Angioedema (HAE) B. Acquired C1 Esterase Deficiency (ACID) B. Acquired C1 Esterase Deficiency (ACID) ✓Acquired C1 Esterase Deficiency (ACID) C. Allergic Reaction C. Allergic Reaction ✓Allergic Reaction D. ACE Inhibitor-associated angioedema D. ACE Inhibitor-associated angioedema ✓ACE Inhibitor-associated angioedema E. All of the above E. All of the above Additional patient history and physical examination will help narrow the differential dx 16 17 18 3 2/16/2019 Angioedema Clinical Presentation Which of the following findings is not consistent with the Which of the following findings is not consistent with the presentation of Hereditary Angioedema (HAE)? presentation of Hereditary Angioedema (HAE)? Patients with Hereditary Angioedema (HAE) present with angioedema A. Abdominal pain A. Abdominal pain and often a family history (but 25% are de novo mutations) B. Nausea, vomiting and diarrhea B. Nausea, vomiting and diarrhea C. Family history of HAE C. Family history of HAE Some typical findings of an IgE mediated response (especially D. Urticaria D. Urticaria urticaria) are typically absent. 19 20 21 Angioedema Clinical Presentation The presence of itching and urticaria would suggest which The presence of itching and urticaria would suggest which diagnosis? diagnosis? A. Hereditary Angioedema (HAE) A. Hereditary Angioedema (HAE) B. Acquired C1 Esterase Deficiency (ACID) B. Acquired C1 Esterase Deficiency (ACID) The presence of itching and urticaria suggest an allergic reaction. C. Allergic Reaction C. Allergic Reaction D. ACE Inhibitor-associated angioedema D. ACE Inhibitor-associated angioedema E. All of the above E. All of the above 22 23 24 4 2/16/2019 The patient provides additional history. She has hypertension, diabetes The patient provides additional history. She has hypertension, diabetes Angioedema Management mellitus, 3 prior coronary stents and no personal or family history of mellitus, 3 prior coronary stents and no personal or family history of angioedema. Medications include glucophage, ramipril and a angioedema. Medications include glucophage, ramipril and a multivitamin. multivitamin. Fresh frozen plasma may be helpful in ACE Inhibitor associated angioedema. Which of the following is the most appropriate next step in Which of the following is the most appropriate next step in management? management? Epinephrine may precipitate an acute coronary syndrome in this A. Administer Epi 1:1000 0.3mg IM A. Administer Epi 1:1000 0.3mg IM elderly, severely hypertensive patient with known coronary artery B. Administer Epi 1:1000 0.5mg IM B. Administer Epi 1:1000 0.5mg IM disease C. Order 2 units of fresh frozen plasma C. Order 2 units of fresh frozen plasma D. Perform immediate cricothyroidotomy D. Perform immediate cricothyroidotomy 25 26 27 Angioedema Management Given the additional history, which medication is least likely to be Given the additional history, which medication is least likely to be effective in relieving this patient’s symptoms? effective in relieving this patient’s symptoms? ✓C1 esterase inhibitor [human] is indicated for HAE, not ACE A. 2 units of fresh frozen plasma A. 2 units of fresh frozen plasma inhibitor associated angioedema. B. Diphenhydramine 50mg IV B. Diphenhydramine 50mg IV C. Famotidine 20mg IV C. Famotidine 20mg IV ✓FFP, H1 and H2 blockers may be beneficial in ACE inhibitor associated angioedema. D. C1 esterase inhibitor [human] D. C1 esterase inhibitor [human] 28 29 30 5 2/16/2019 Angioedema Management The patient just remembers that she actually ran out of her The patient just remembers that she actually ran out of her ramipril two years ago. Her husband tells you that her cousin ramipril two years ago. Her husband tells you that her cousin Joyce and daughter Cynthia had the “same thing happen to them Joyce and daughter Cynthia had the “same thing happen to them last year.” Appropriate laboratory tests might include last year.” Appropriate laboratory tests might include Given the absence of an ACE inhibitor, ACEI associated angioedema is impossible. A. CBC A. CBC Her family history suggests Hereditary Angioedema. C4 and C1 B. C2, C4, C1q, C1-inhibitor B. C2, C4, C1q, C1-inhibitor esterase inhibitors are useful in this diagnosis. In the US, the C1 C. Troponin C. Troponin esterase inhibitor function is insensitive (C4 will be low at D. Liver transaminases D. Liver transaminases baseline and during an attack) 31 32 33 1 week later, one of your attending physicians is reviewing lab 1 week later, one of your attending physicians is reviewing lab References: results that returned after patient discharge. She notices that one results that returned after patient discharge. She notices that one of your patients had a C1 inhibitor and C4 that were “low” and of your patients had a C1 inhibitor and C4 that were “low” and US Hereditary Angioedema Association. Diagnosing HAE. wants to know what to do with this result. You tell her: wants to know what to do with this result. You tell her: http://www.haea.org/professionals/diagnosing-hae. Accessed online: 1/9/16. A. This rules out Hereditary Angioedema in your patient from A. This rules out Hereditary Angioedema in your patient from Tran TP and Muelleman RL. Allergy, Hypersensitivity, and Anaphylaxis. In: last week. Please notify the patient. last week. Please notify the patient. Marx JA, Hockberger RS, Walls RM. eds. Rosen’s Emergency Medicine – B. This rules in Hereditary Angioedema in your patient from last B. This is suggestive of Hereditary Angioedema in your Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Elsevier/Saunders, week. Please notify the patient. patient from last week. Please notify the patient. 2010 C. I don’t really know why I drew that test. Just check physician C. I don’t really know why I drew that test. Just check physician aware. aware. 34 35 36 6 2/16/2019 Asthma: A 15 year old female with history of asthma developed shortness Appropriate initial stabilization includes all of the following of breath 1 hour ago. On arrival to the ED, she is awake, alert, except: 1.8 million ED visits (2011) and appears mildly anxious. A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 BP: 140/80, HR 110, RR 34, T 36 C and SPO2 is 89% on room doses air. 3,630 deaths (2013) B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, mixed with albuterol solution On physical examination, the patient is sitting upright, slightly anxious, with tachypnea. Lung sounds are diminished with faint C. Oxygen therapy 219 deaths of children wheezing. (2013) D. Prednisone 40-60mg E. Theophylline 5mg/kg PO 37 38 39 Asthma Management Appropriate initial stabilization includes all of the following While all of the below conditions limit airflow in asthma, ______ except: may decrease the response to therapy by causing permanent ✓IV access for severe exacerbations structural changes. A. Nebulized albuterol solution 1.25 mg every 20-30 minute x 3 ✓Pulse oximetry doses ✓Maintain SaO2 >90% A. Bronchial constriction B. Nebulized ipratropium 0.5mg every 20-30 minutes x 3 doses, ✓Nebulized albuterol solution (short acting inhaled B2 agonist) B. Bronchial edema mixed with albuterol solution ✓Systemic corticosteroids for all moderate to severe attacks C. Mucous plugging C. Oxygen therapy ✓Ipratropium bromide may be added to first 3 albuterol treatments for severe exacerbations D. Airway remodeling D. Prednisone 40-60mg ✓Methylxanthines (theophylline) and Leukotriene modifiers E. All of the above E. Theophylline 5mg/kg PO (montelukast) not recommended in acute setting 40 41 42 7 2/16/2019 Asthma Pathophysiology While all of the below conditions limit airflow in asthma, ______ may decrease the response to therapy by causing permanent structural changes. • Bronchospasm True or False: Early Response • Edema A. Bronchial constriction • Airflow Obstruction Asthma is a chronic inflammatory condition B. Bronchial edema associated with bronchial hyper responsiveness C. Mucous plugging and some reversibility • Airway inflammation D. Airway remodeling Late Response • Airflow obstruction E. All of the above • Airway Hyper response Adapted from Figure 71-3 Rosen Ch 71 p 890 43 44 45 Asthma Pathophysiology Asthma Management True or False: ✓IV steroids are not more effective than PO Asthma is a chronic inflammatory condition steroids … unless the patient cannot tolerate associated with bronchial hyper responsiveness IV steroids are more effective than PO steroids oral intake and some reversibility ✓Give steroids promptly in severe attacks ✓Effects begin within hours (peak at 24 hours) 46 47 48 8 2/16/2019 You have actively managed the patient for 1 hour.
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