Angioedema in the Emergency Department: An Evidence-Based Update (Pharmacology CME) -
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Publication Date: October 2022 (Volume 24, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 10/01/2025.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Prayag Mehta, MD

Assistant Professor, Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX

Nikola Milanko, MD

Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX

Jedediah Leaf, MD

Associate Program Director, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX

Joshua Kern, MD

Assistant Professor, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX

Peer Reviewers

Charlotte Goldfine, MD

Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

Ashley Booth Norse, MD

Associate Chair of Operations, Professor of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL

Abstract

Angioedema is a histamine-or bradykinin-mediated response that can be acquired, hereditary, or idiopathic. Manifestations include nonpitting edema of the subcutaneous layer of the skin or submucosal layers of the respiratory or gastrointestinal tracts. While acute presentations are typically transient and localized, angioedema can result in acute airway compromise, requiring immediate stabilization. It can also result in abdominal pain that is commonly misdiagnosed, resulting in unnecessary and potentially harmful procedures. This review assesses current literature on the etiology and management of angioedema in the emergency department. An analysis of the most recent evidence on therapeutic options is provided, while addressing barriers to use.

Case Presentations

CASE 1

A 23-year-old man presents by EMS with abdominal pain…

The patient reports that for the past 4 hours he has had generalized abdominal pain that is sharp, constant, and increasing in intensity. He has associated nausea and nonbloody emesis. He denies fever, back pain, urinary complaints, chest pain, shortness of breath, or penile discharge. He denies recent NSAID, antibiotic, or drug or alcohol use, as well as recent travel or sick contacts. He states his father’s lips occasionally swell but does not know any other details of the condition. He does report having multiple similar occurrences of this abdominal pain, but with negative lab testing and imaging.
His vital signs are: temperature, 36.6C°; heart rate, 112 beats/min; blood pressure, 104/70 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 100% on room air.
His abdomen is soft, moderately distended, and diffusely tender to palpation without guarding or rebound. His genital exam is unremarkable. You are concerned for a surgical abdomen, but the recurrent nature of the presentation makes you suspicious that something else is going on…

CASE 2

A 48-year-old woman presents to the ED with lip swelling…

She states her lips felt “heavy” when she woke up this morning, but over the past 8 hours, she has noticed significant swelling. She denies shortness of breath, voice change, rash, or prior history of similar occurrences, as well as fever or infection, any known allergies, or significant family history. She said she has had no recent exposures, travel, or trauma.
The patient’s past medical history includes hypertension, diabetes mellitus type 2, and hyperlipidemia. She reports that she currently takes lisinopril, metformin, and atorvastatin.
Her vital signs are: temperature, 37C°; heart rate, 82 beats/min; blood pressure, 138/78 mm Hg; respiratory rate, 16 breaths/min; and oxygen saturation, 100% on room air.
On examination, the patient is in no distress, but she has significant upper and lower lip swelling, with no oropharyngeal involvement. The rest of her examination is unremarkable. You wonder whether
her condition will progress and whether you should administer corticosteroids and antihistamines and proactively intubate her…

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