A consensus parameter for the evaluation and management of angioedema in the emergency department

Abstract

Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).

Figure 1. Algorithmic Approach to the Management of Angioedema in the ED

Employing a simple classification scheme for angioedema can help in developing an efficient and effective approach to assessing and managing patients presenting with angioedema. The first step in managing any patient in the emergency department is to sufficiently manage the airway and breathing, as well as to support circulatory function if necessary. Once the patient is stabilized a focused history and physical should be obtained to separate bradykinin-mediated (ACE-induced, HAE) from histamine-mediated. Subsequent distinctions between the underlying causes of angioedema can then be made to ensure appropriate longitudinal management and follow-up care. If the patient is on an ACE inhibitor, stop medication and provide airway management support. If the patient has a known history of hereditary angioedema, treat according to HAE guidelines using one of the recommended “on demand” therapies (Table 2).(37) If the patient has signs of anaphylaxis (i.e., hypotension, vomiting, vasculature instability), administer epinephrine and treat according to anaphylaxis guidelines.(48)