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PRESENTATION #3 Case Report | Fundamentals of Anesthesiology

SEVERE OROLINGUAL ANGIOEDEMA AFTER THROMBOLYTIC THERAPY IN A STROKE PATIENT: A CASE REPORT

Muhammad Anwar, M.B.B.S., Katherine Cox, M.D.
Tulane School of Medicine

Presenter: Muhammad Anwar, MBBS
Tulane School of Medicine

A 48-year-old obese African American man with a PMH of Down syndrome, DM, and hypertension managed with an ACEI, was referred to our facility from an outside hospital where he initially presented with right-sided stroke. Telestroke service was consulted and a bolus of tPA was administered followed by transfer to a tertiary care hospital for further management. His initial vital signs upon presentation to our emergency department showed BP 205/114, HR 99 bpm, RR 22/min, and a SaO2 of 100% on 15 liters Oxygen via a nonrebreather mask. Physical exam revealed marked swelling of the tongue, which was not present prior to the tPA bolus.

Anesthesiology was consulted for intubation in the setting of impending respiratory failure secondary to severe angioedema. A fiber-optic bronchoscope was used for nasal intubation after applying 2% lidocaine to nares and administration of 8mcg of Dexmedetomidine. Under direct visualization of glottic opening, a 6.5 mm cuffed endotracheal tube was passed through the vocal cords. Placement was confirmed by a positive color change on a colorimetric device and auscultation. Bite blocks were placed to prevent the patient from biting on his tongue.

Subsequently etomidate, dexmedetomidine, and rocuronium were given. Neurosurgery team performed an emergent thrombectomy for a left MCA thrombus. Postoperatively the angioedema was managed using a combination of racemic epinephrine, hydrocortisone, methylprednisolone, dexamethasone, and antihistamines. On hospital day 8, he underwent tracheostomy by Otolaryngology team due to continued angioedema.

During the next several days, he received Botox injections in the medial pterygoid muscles. A tongue biopsy revealed extensive acute on chronic inflammation along with tissue necrosis. The patient’s family was offered a choice between partial glossectomy and conservative therapy, of which they opted for the latter. The patient was discharged to a long-term acute care facility after a 52-days inpatient stay.