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?
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
Sounds like a hemophiliac . I would go with answer B. Get ready for him to bleed
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
EPIDEMIOLOGY & DEMOGRAPHICS
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.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
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
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.
1. Is tooth extraction a trigger of angioedema? What's your understanding?
2. Why IV access? The actual answer is "secure airway!"
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