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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Airway
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.
