Tooth extraction complication case - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
USMLE Articles
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam

Thread Tools Search this Thread Display Modes
Old 06-19-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,241 Times in 441 Posts
Reputation: 1255
Blood Tooth extraction complication case

A young man presents to the emergency department with a complaint of an uncomfortable full feeling in his throat. The feeling started as a tingling sensation about 2 hours ago following a tooth extraction. The patient has had these episodes twice before, both times while playing football. In both cases, the symptoms resolved in a few hours. This time the sensation is stronger and the patient is extremely nervous, although he cannot say why. The emergency department intern obtains a more detailed history and learns that for years, the patient has also experienced episodes of skin swelling following a minor trauma such as a banging an arm against an object. This swelling is a painless, raised, sharply demarcated region with irregular borders that disappears after a few days. Which of the following is the most appropriate next step in management?

Answer Choices
A. Give fresh-frozen plasma now
B. Insert large-bore peripheral intravenous line
C. Obtain a computed tomography scan of the neck and chest
D. Obtain lateral neck films
E. Obtain throat cultures
Reply With Quote Quick reply to this message

Old 06-19-2011
aksyonez's Avatar
USMLE Forums Veteran
Steps History: 1+CK+CS
Posts: 218
Threads: 74
Thanked 114 Times in 63 Posts
Reputation: 126

Sounds like a hemophiliac . I would go with answer B. Get ready for him to bleed
Reply With Quote Quick reply to this message
Old 06-19-2011
USMLE Forums Scout
Steps History: CK+CS
Posts: 21
Threads: 2
Thanked 5 Times in 3 Posts
Reputation: 15

seems like hereditary angioedema so ans would be A ... give FFP .
Reply With Quote Quick reply to this message
Old 06-20-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,241 Times in 441 Posts
Reputation: 1255

Option B (Insert large-bore peripheral intravenous line) is correct. Securing the patient’s airway is the first priority. Laryngeal angioedema presents great difficulties to intubation, and the most experienced personnel should be involved in this procedure. Acute attacks can cause massive sequestration of fluids requiring aggressive intravenous volume resuscitation.

Option A (Give fresh-frozen plasma now) is incorrect. Administration of fresh-frozen plasma (FFP) is the treatment for patients with hereditary angioedema before dental procedures or other mechanical manipulation of the airway. Giving FFP during an acute attack provides components for complement consumption that could increase the severity and duration of the episode.

Option C (Obtain a computed tomography scan of the neck and chest) is incorrect. The patient should not be transported to radiology. He is at high risk of acute laryngeal angioedema and complete airway obstruction.

Option D (Obtain lateral neck films) is incorrect. The patient should not be transported to radiology. He is at high risk of acute laryngeal angioedema and complete airway obstruction.

Option E (Obtain throat cultures) is incorrect. The patient’s history and presentation are classic for C1 esterase deficiency or hereditary angioedema. This patient is probably experiencing acute laryngeal edema. Any physical manipulation of the tongue or contact with the throat is likely to trigger complete airway obstruction.

High-yield Hit 1
Approximately 20% of the population experiences urticaria and/or angioedema at some time during life.
Race: No predilection.
Sex: More occurrences in women than men.
Angioedema can occur together with urticaria (40%) or alone (20%); the remaining 40% have urticaria alone
Angioedema commonly occurs after adolescence in the third decade of life.
Incidence of hereditary angioedema is 1/150,000 persons.
Angioedema may be acute or chronic.
Acute angioedema is defined as symptoms lasting 6 wk.
Chronic angioedema is defined as symptoms lasting >6 wk.
Urticaria is commonly known as "hives" and is:
Millimeters to centimeters in size
Multiple in number
Fades within 12 to 24 hr
Reappears at other sites
Angioedema is characterized by the following:
Not well demarcated
Involves eyelids (Fig. 1-17), lips, tongue, and extremities
Can involve the larynx causing respiratory distress
Resolves slowly

Figure 1-17 Angioedema of the upper lip, with severe swelling of deeper tissues. (From Goldstein BG, Goldstein AO: Practical dermatology, ed 2, St Louis, 1997, Mosby.)
Angioedema, with or without urticaria, is classified as acquired (allergic or idiopathic) or hereditary.
Angioedema is primarily due to mast cell activation and degranulation with release of vasoactive mediators (e.g., histamine, serotonin, bradykinins) resulting in postcapillary venule inflammation, vascular leakage, and edema in the deep layers of the dermis and subcutaneous tissue.
Pathologically angioedema has both immunological and nonimmunological mediated mechanisms.
Immunoglobulin E (Ig E)-mediated angioedema may result from antigen exposure (e.g., foods [milk, eggs, peanuts, shell fish, tomatoes, chocolate, sulfites] or drugs [penicillin, aspirin, NSAIDs, phenytoin, sulfonamides]).
Complement-mediated angioedema involving immune complex mechanisms can also lead to mast cell activation that manifests as serum sickness.
Hereditary angioedema is an autosomal dominant disease caused by a deficiency of C1 esterase inhibitor (C1-INH). C1-INH is a protease inhibitor that is normally present in high concentrations in the plasma. C1-INH serves many functions, one of which is to inhibit plasma kallikrein, a protease that cleaves kininogen and releases bradykinin. A deficiency in C1-INH results in excess concentration of kininogen and the subsequent release of kinin mediators.
Acquired angioedema is usually associated with other diseases, most commonly B-cell lympho-proliferative disorders, but may also result from the formation of autoantibodies directed against C1 inhibitor protein.
Other causes of angioedema include infection (e.g., herpes simplex, hepatitis B, coxsackie A and B, streptococcus, candida, ascaris, and strongyloides), insect bites and stings, stress, physical factors (e.g., cold, exercise, pressure, and vibration), connective tissue diseases (e.g., SLE, Henoch-Schönlein purpura), and idiopathic causes. ACE inhibitors can increase kinin activity and lead to angioedema.

Taken from Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 2

10. What options are available for treating acute upper airway obstruction?

Clinically stable (nonadvancing), mild to moderate airway obstruction can be treated with careful observation alone. However, medical therapy and observation are often required during progressive or severe symptoms. Thus, observation must occur in an intensive care unit (ICU), where personnel can capably assess the airway and intervene. Artificial airways (see question 13) are often quite useful. However, endotracheal intubation may be necessary when these measures fail. If intubation is unsuccessful, an emergent surgical airway (cricothyrotomy or tracheotomy) is necessary to ensure adequate ventilation.
Reply With Quote Quick reply to this message
Old 06-20-2011
1TA2B's Avatar
USMLE Forums Guru
Steps History: CK Only
Posts: 476
Threads: 39
Thanked 351 Times in 169 Posts
Reputation: 374

1. Is tooth extraction a trigger of angioedema? What's your understanding?

2. Why IV access? The actual answer is "secure airway!"

To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

Reply With Quote Quick reply to this message


Emergency-Medicine, Internal-Medicine-, Step-2-Questions

Quick Reply

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Please enter a password for your user account. Note that passwords are case-sensitive.
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Where you live. Leave blank if you don't want to tell.


Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.

Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes

Similar Threads
Thread Thread Starter Forum Replies Last Post
Most accurate test for Charcot - Marie - Tooth Disease kemoo USMLE Step 2 CK Forum 2 06-17-2011 10:37 AM
Complication of D & C step1an USMLE Step 1 Forum 11 09-06-2010 07:18 AM
Pt with h/o prolonged bleeding after tooth extraction doctorF USMLE Step 1 Forum 10 07-21-2010 09:09 AM
Erosive Arthropathy as a complication Yallah USMLE Step 1 Forum 4 06-21-2010 11:08 AM
Fallen tooth malik USMLE Step 2 CS Forum 1 07-11-2009 04:28 PM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2016 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)