Case Report: Upper Airway Obstruction in the Emergency Department

A 25-year-old female with history of shellfish allergy presented to the emergency department (ED) via ambulance with the complaint of difficulty breathing. The patient was previously at dinner when she became acutely short of breath and had difficulty speaking.

On arrival to the scene, EMS noted a woman in respiratory distress, sitting with her hands on her knees and leaning forward. She had a muffled voice and difficulty with phonation. Vitals on scene included HR 112, blood pressure 130/82, and 99 percent oxygen saturation on room air. EMS placed the patient on nasal cannula for comfort and brought her to the ED. On arrival to the emergency department, she was sitting in a tripod position, unable to phonate with inspiratory stridor, and spitting saliva into an emesis basin. Vitals revealed that she was afebrile, mild tachycardia of 115 beats per minute, tachypnea, BP 120/80, and 100 percent oxygen saturation on room air. As she could not phonate, the patient was only able to shake and nod her head to questions. Per history, it was determined that her symptoms had started two days prior, but acutely worsened after eating “surf and turf” for dinner prior to arrival. She endorsed inability to speak, dysphagia, odynophagia, and shortness of breath. She reported a similar prior episode but not as severe as her current presentation. She denied rash, nausea, vomiting, chest pain, choking sensation, eating food with bones, family history of facial or tongue swelling, or taking any medications at home including angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Physical exam revealed a clear oropharynx with no appreciable lesion, edema, or uvular deviation. Palpation of her neck revealed fullness without induration or erythema. She had equal, clear breath sounds bilaterally with no wheezing. Cardiovascular exam was without pathologic finding. Patient had no appreciable rash.

Intravenous access was obtained and equipment for difficult airway management was brought to the bedside. Anesthesia and otolaryngology were emergently paged to the department. Intramuscular epinephrine as well as intravenous methylprednisolone, diphenhydramine, and famotidine were administered. A lactated ringers bolus was started. As her oxygen saturation was normal, it was felt that a surgical airway was not immediately indicated. Anesthesia arrived and prepared for fiber-optic laryngoscopy, with a working diagnosis of likely angioedema given her shellfish allergy and having consumed seafood. Prior to initiation of this procedure, the patient began to close her eyes, and required repeat stimulation to maintain alertness. She was kept upright and awake, with nebulized lidocaine as the only pre-treatment measure.