HEMATOLOGY, ONCOLOGY, ALLERGY,AND IMMUNOLOGYTREATMENT
■ Stop offending agent.
■ Ensure adequate airway, supplemental O 2 , IV fluids.
■ Epinephrine,0.3–0.5 mg (1:1000) IM (pediatric, 0.01 mL/kg)
■ Generally, reserve epinephrine for patients with hypotension or airway
complaints (swelling, voice change, difficulty breathing). Patients with car-
diovascular collapse should receive intravenous epinephrine (0.1 mg IV
over 5 minutes).
■ H 1 blocker(diphenhydramine) and H 2 blocker (ranitidine, famotidine)
■ Steroids(prednisone, methylprednisolone)
■ Albuterol for bronchospasm
■ Glucagon:For patients on β-blockers who are refractory to fluids and
epinephrine
■ Observe patients who receive epinephrine for at least 4 hours prior to dis-
charge. Admit patients with recurrent symptoms.
A 40-year-old male with hypertension presents with angioedema involving
his tongue. He was prescribed an ACE inhibitor last month. After treatment
with steroids, H 1 /H 2 blockers, and epinephrine, he reports feeling better
but continues to have swelling on exam. Nasopharyngoscopy shows laryngeal
edema. What is the patient’s disposition?
Admit to ICU to closely monitor his airway.Angioedema
Edema of the deeper dermal and subcutaneous layers of the skin
CAUSES
■ Hereditary angioedema, an autosomal dominant hereditary disorder asso-
ciated with C1 inhibitor deficiency
■ ACE inhibitor (ACE-I) or angiotensin II receptor blockers use, mediated
through bradykinin and substance P
■ IgE-mediated hypersensitivity
■ Direct mast cell stimulation
SYMPTOMS/EXAM
■ Edema may occur anywhere in the body but most concerning is its involve-
ment with tongue, face, and neck.
■ Other common locations involve hands, feet, eyelids, and scrotum.
■ Upper airway involvement may lead to dyspnea, cough, hoarseness, stridor.
DIAGNOSIS
■ Clinical diagnosis but may obtain a C4 level to screen for hereditary
angioedema (HAE); the C4 level is usually low in affected individuals
■ Nasopharyngoscopy can be used to evaluate for laryngeal edema.
TREATMENT
■ Stop offending medication.
■ First-line agent = antihistamines (H 1 /H 2 blockers).
■ Epinephrine can be used for severe cases.
■ Corticosteroids may help limit response.
Sixty percent of cases of ACE-I-
induced angioedema occurs
within 1 week of starting the
medication. It may, however,
occur years after starting the
medication.