Evaluation and Management of Angioedema in the Emergency Department

West J Emerg Med. 2019 Jul;20(4):587-600. doi: 10.5811/westjem.2019.5.42650. Epub 2019 Jul 2.

Abstract

Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.

Publication types

  • Review

MeSH terms

  • Airway Management
  • Algorithms
  • Angioedema / etiology*
  • Angioedema / therapy*
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Blood Coagulation Factors / therapeutic use
  • Bradykinin / analogs & derivatives
  • Bradykinin / metabolism
  • Bradykinin / therapeutic use
  • Bradykinin B2 Receptor Antagonists / therapeutic use
  • Bronchodilator Agents / therapeutic use
  • Emergency Service, Hospital*
  • Epinephrine / therapeutic use
  • Glucocorticoids / therapeutic use
  • Histamine / metabolism
  • Histamine Antagonists / therapeutic use
  • Humans
  • Peptides / therapeutic use
  • Plasma
  • Urticaria / etiology

Substances

  • Anti-Inflammatory Agents, Non-Steroidal
  • Blood Coagulation Factors
  • Bradykinin B2 Receptor Antagonists
  • Bronchodilator Agents
  • Glucocorticoids
  • Histamine Antagonists
  • Peptides
  • prothrombin complex concentrates
  • ecallantide
  • icatibant
  • Histamine
  • Bradykinin
  • Epinephrine