Triage Algorithm for a Patient with Angioedema of the Head and Neck

 

If the event is associated with an inciting drug or agent, then this should be stopped immediately. The drug most often implicated is an angiotensin converting enzyme (ACE) inhibitor.

 

If the patient is immediate distress, then the airway must first be secured.

(1) If there is sufficient time, then this can be performed in the OR.

(2) Else use fiberoptic intubation, tracheotomy or direct laryngoscopy.

 

If the patient has severe disease but is not in immediate distress, then they should be admitted to the ICU. This group includes:

(1) patients with laryngeal edema

(2) patients with diffuse enlargement of the tongue so that the soft palate is obscured.

 

Patients with more severe disease requiring ICU admission show one or more of the following:

(1) voice change (muffled, stertorous, other)

(2) hoarseness

(3) dyspnea

(4) stridor

 

If the patient is not in immediate distress and shows a moderate degree of tongue edema, then the patient should be admitted to an inpatient ward. If the patient does not improve or worsens, then the patient should be admitted to the ICU.

 

Inpatient management with no immediate distress and/or once airway secure:

(1) consider C1-INH concentrate, if available (treatment of choice)

(2) consider infusion of 1-2 units of fresh frozen plasma

(3) consider tranexamic acid (anti-fibronolytic) , up to 8 grams (may cause thrombosis)

 

Patients with mild disease and who appear to be stable can be managed as an outpatient, provided there is someone able to keep an eye on the patient and emergency medical care is available. This includes:

(1) patients with facial or soft palate edema only

(2) patients with mild tongue edema with the soft palate readily visible.

 

Outpatient management (according to Ishoo et al) :

(1) consider oral steroids

(2) epinephrine auto-injector

(3) followup.

 

NOTE: Ebo and Stevens (2000) indicate that oral steroids, epinephrine and antihistamines are commonly used but have no proven efficacy.