# Angeoedema



## 8'Duece (Jun 2, 2009)

I worked the ER last night and for the first time I witnessed a case of Angioedema.  Basically the patient had what seemed to be anaphalytic shock, but it's more known to be an alergen reaction or sometimes just idiopathic in nature. 

The doctor could not get an airway for the induction of  and intubation tube and her O2 sats where dropping.  He had to induce IV meds to perform an emergency Trach. :eek:  She was given a drip of epinephrine which is known to save a persons life should the condition be an allergic reaction. 

My question for combat medics (18D/PJ's) is do you carry this type of medication should a soldier experience Andgioedema ?? Would you immediatley intubate if the throat is of such nature to actually get an intubation down the patients throat or is the use of Epinephrine IM or IV appropriate ???

Is it best to immediatly intubate or treat with an pharmo IV or IM injection ?


I'm new to these things in the ER, but interested in the Combat Medic side of the onset of this particular condition. Nurses chime in also if you want. 


If it's an OPSEC issue then I apologize and don't mind if you tell me to shut the fugg up. ;)


----------



## HoosierAnnie (Jun 2, 2009)

We had a case come in through our ER just the other night.  The only times I've seen this is as a complication of an allergic reaction.  Observation for just this sort of thing is one of the reasons behind an overnight stay with such reactions.

In the cases I've seen, automatic intubation has not been done.  Sure you provide extra O2 if needed, cause some experience only some slight swelling and are able to maintain adequate sats with just a lil supplimental O's.  When the patient begins to show signs that they cannot maintain their own airway, that's when intubation gets done.  At least in the ER, out in the field things could work under different protocols.  Drug route of choice is IV, absorbtion from an IM is just to frigging slow in an emergent situation.  Once you get the tube down, you can also give epi down the tube itself if you do not have an IV line established.

Epi is the first line drug, (think epi pens for bee sting allergies) given to combat the histaminic release caused by the allergen exposure.  In most cases, you will also see IV steroid, like solumedrol, given both as a load dose  in ER and then scheduled doses during the first 24-48 hrs.  Sometimes even followed by an oral steroid "quick taper".  This is to help reduce the inflammation of the airway / decrease the swelling.

Just the $0.02 of a "*R*eal *N*ut"


----------



## Muppet (Jun 2, 2009)

Angioedema is similar to an allergic reaction. W/O getting into patho-phys. it can cause shock (Profound vasodilation/lung constricton, third spacing, dis. shock).
Treatment: 
-Minimal: Benadryl, 50mg (histamine reaction), Solu-medrol,125 mg, (inflamation, 4-6 hrs onset)
-Major: Add Epi, 1,1000 (vaso-constrictor/bronchodilator and histamine blocker) I.M. or I.V., 1,10.000, 0.1mg slow I.V.
-Bronchospams: Add Albuterol.
-Shock/non-breather: Tube/cric and fluids.
-Really bad: Add pressors (Dopamine).

It depends on the provider and as Annie said, it depends in the situation. I have tubed/cric'd then given meds. and I have waited and given meds. first. I had a guy a couple weeks ago that had Angioedema and edema in the mouth. I went with meds. first and prepped his neck. His tongue was the size of a car so a tube was out of the question. The meds. worked. Angioedema occurs sub-dermally and allergic reactions occur dermally causing the wheals and urticaria.

F.M.


----------



## Muppet (Jun 2, 2009)

HoosierAnnie said:


> We had a case come in through our ER just the other night.  The only times I've seen this is as a complication of an allergic reaction.  Observation for just this sort of thing is one of the reasons behind an overnight stay with such reactions.
> 
> In the cases I've seen, automatic intubation has not been done.  Sure you provide extra O2 if needed, cause some experience only some slight swelling and are able to maintain adequate sats with just a lil supplimental O's.  When the patient begins to show signs that they cannot maintain their own airway, that's when intubation gets done.  At least in the ER, out in the field things could work under different protocols.  Drug route of choice is IV, absorbtion from an IM is just to frigging slow in an emergent situation.  Once you get the tube down, you can also give epi down the tube itself if you do not have an IV line established.
> 
> ...




Priceless Annie. I love it. (Real Nut).

F.M.


----------



## Diamondback 2/2 (Jun 2, 2009)

I am no medic and I am a retard when it comes to medical shit, but I have done a make shift tracheotomy on an Iraqi. All our CLS “surgeons” were taught how to do them when we lost a soldier to GSW to the face.

We were taught “in the field” that you attempt to open the air way twice, after that you do a trach and open the soldier’s airway… Better to get them breathing then to risk the fuck, fuck games. 

Obviously our circumstances were very different and our actions were not dealt with in a professional manner. But it was a matter of shit or get off the pot.

So yep this will not be helpful to you what’s so ever!


----------



## Muppet (Jun 2, 2009)

J.A.B. said:


> I am no medic and I am a retard when it comes to medical shit, but I have done a make shift tracheotomy on an Iraqi. All our CLS “surgeons” were taught how to do them when we lost a soldier to GSW to the face.
> 
> We were taught “in the field” that you attempt to open the air way twice, after that you do a trach and open the soldier’s airway… Better to get them breathing then to risk the fuck, fuck games.
> 
> ...




I will not say that. This is an EDUCATIONAL site and your experience shows us what had to be done to save a life. Nothing more or less. So it is appreciated but I did get a laugh from your comment.

F.M.


----------



## fox1371 (Jun 2, 2009)

J.A.B. said:


> I am no medic and I am a retard when it comes to medical shit, but I have done a make shift tracheotomy on an Iraqi. All our CLS “surgeons” were taught how to do them when we lost a soldier to GSW to the face.
> 
> We were taught “in the field” that you attempt to open the air way twice, after that you do a trach and open the soldier’s airway… Better to get them breathing then to risk the fuck, fuck games.
> 
> ...




I haven't had to do it but I've also been taught the same thing.  Told to use it as a last resort of course...but trained not to hesitate to do it as well.  Rather have a hole in the neck and live to see the next day.


----------



## DoctorDoom (Aug 4, 2009)

IM is the preferred route of administration of epinephrine for anaphylaxis unless the patient is monitored and in extremis.  IV epi's cardiac effects make it not something to be given without careful monitoring.  Epi-pen injectors are the most common first line treatment for anaphylactic angioedema.  

Intubation always takes place first; ABC's always...  usually recognizing anaphylaxis and the admin on IM will preclude the need for emergent airways.  Emergent trachs should be avoided by inexperienced providers; there are other options.


----------



## amlove21 (Aug 4, 2009)

i echo doom/annie on this one- and you have to think of the situation. If there are bullets flying and I am first to touch the patient, i am most likely moving, shooting, communicating and thinking about what im going to do once my patient and i are safe. After that, i would go ABC, see if there is some sort of easy fix. Angioedema is, most likely, not on my short list of stuff I are looking for, but yes, we do carry epi in 1/1 and 1/10 concentrations, along with diphenhydramine and some other stuff. A drug that is GREAT for this specific example is Terbutaline- less "sledgehammer" than epi's "all inclusive alpha beta" effects, more "sniper" to the Beta 2. Good tolerance for adult asthma, where dysrhythmia isnt a concern. 

As far as airways, go easy to hardest. I dont see every patient as a slice and a shiley. I would rather ADJUST FIRST, oro/nasal, LMA, intubate, crich. You have to remember with a field crich- the likelihood of you performing it PERFECTLY with zero complications is sitting around 40%. Intubations without complication in a field setting is only about 60%. LMAs, like the intubating LMA's, are showing to have a MUCH greater efficacy. And considering that it takes about 1/4 of the time AND you can intubate through it if you wish, thats what i would go with. Just my opinion.


----------



## DoctorDoom (Aug 4, 2009)

Just to clarify, 82nd, you saw an emergent trach or a cric?  They are quite different...


----------



## Ajax (Aug 5, 2009)

I don't know that I'd be able to tell the difference between angioedema and ana p in the field (or in the hospital for that manner).  

On the intubation question, it would really depend on the physical presentation of the patient.  If the airway appears compromised, I would always take care of that before meds (with the excpetion of RSI meds).  Handling something like this, there are generally enough hands floating around the patient that I don't think I would have to choose one or the other (Hey you, take that needle and put in that there muscle...no, the other one.)  And yeah, I go IM over IV  *UNLESS* I'm in the middle of doing IO.  I'm a big fan of IO.

In an emergency setting, I don't premedicate for a cric/trach.  Of course, I'm not really into the sterile technique for this procedure either.


----------



## 8'Duece (Aug 5, 2009)

What's a "Cric ?" :uhh:  Sorry, these things are new to me. 

Can you do a Cric or Trach with a C-Spine ??


----------



## Muppet (Aug 9, 2009)

82ndtrooper said:


> What's a "Cric ?" :uhh:  Sorry, these things are new to me.
> 
> Can you do a Cric or Trach with a C-Spine ??




Cric: Needle or surgical and yes you can preform them with spinal stab. in progress. Find the crico-thyroid membrane and either puncture of cut, we in civilian EMS use the quick-trach pre-assembled kit. Does it fast.

F.M.


----------



## medic1 (Aug 12, 2009)

Hi Guys
My thoughts are, as a Medic in the field without all the clinical exams you can do in the ER....treat what you see! if the guys in shock......IV, adrenaline ... if there is an airway problem Intubate/ Surgical Cric. Stabilize the casualty, and evac them to people who have the gadgets to analyze..........

Medic 1


----------

