Critical Care Casebook: Episode 1
Show Notes:
1. Initial Approach
Differentiate histamine vs bradykinin-mediated angioedema, but in practice, treat as histamine-mediated first (epi, steroids, antihistamines) since it’s readily accessible and time-sensitive.
If no response → consider bradykinin-targeted therapies (TXA, FFP). Evidence is limited. FFP may even worsen bradykinin angioedema as it contains bradykinin.
2. Airway Preparation
Early airway planning is critical. Signs like tripod position, hot potato voice, tongue swelling → strong predictors of impending airway compromise.
Always prepare in parallel: medications, IV access, airway equipment (video laryngoscope, fiberoptic scope, cricothyrotomy supplies).
Preparation reduces anxiety—marking the cricothyroid membrane “de-adrenalizes the room” and mentally primes the team.
3. Awake Intubation Strategy
Ketamine-only intubation is preferred for angioedema to preserve spontaneous respirations. Dose: ~2 mg/kg. Consider small aliquots (e.g., 25 mg increments) to avoid apnea and excessive secretions.
Fiberoptic intubation via nasal route is commonly used. Pre-dilate with a nasal trumpet or ET tube
Right nostril often has faster success and less epistaxis (Tan 2021) ; bevel orientation may be better “up” rather than toward the septum (Won 2021).
Always pass through the lower turbinate passage for easier access.
Have paralytics (e.g., rocuronium) ready if cords are visualized but not passable.
4. Backup & Adjuncts
Cricothyrotomy readiness (scalpel–finger–bougie) is essential; mark or at least palpate the neck beforehand.
Consider glycopyrrolate for secretion control (delayed onset).
Have push-dose pressors available (phenylephrine if epinephrine not stocked).
