Doctor. There is a new Rash. TPA already given.

R.E.B.E.L. EM post as knowledge source on this topic.

1 to 5% of my patients who get TPA for ischemic stroke really?


I learned about this after 12 yrs of being an emergency medicine attending I had given a lady of 90 yrs of age, TPA for acute dysarthria within 3 hrs of onset.

Just had gotten the full dose of the TPA. Within an hour of completed infusion.

Pt being assessed by MICU for close observation. Hives start on her left cheek.

I gave Benadryl. TPA allergy?

No other part of her body with itchiness or rash. Then her upper lip started to swell. I have Pepcid and Steroids methylprednisolone. But soon afterwards her Left side of her face swelled up.

Very disfiguring, the family freaking out, the patient with dysarthria freaking out. As the former Football announcer Keith Jackson would say "Woah...Nelly?"

I hadn't thought epinephrine would work since I usually doesn't work for any other angioedema hereditary or Ace Inhibitor associated.


I knew the swelling of her face was acute (like above but add 70 years of age). Her upper airway could decompensate so quickly.

I intubated her only after performing a laryngeal handshake. I hope to avoid cutting her neck for an emergent surgical airway if I failed to intubate her. Hemorrhage despite cryoprecipitate.... No way Jose.


Awake intubation with Etomidate only. Bp was high and didn't want to exacerbate it with Ketamine.

I had my King LTSD ready as a back up in case I failed my intubation and needed Rescue Oxygenation.

Too bad no intubating King LTSD from VBM, the germans, here yet.

I was lucky, the intubation was smooth. She had been ramped up. head up with ear to sternal notch alignment. Preoxygenated. Video Laryngoscopy used via the Glidescope.

Her gag wasn't that strong despite sedation induction only intubation. Fortunately the swelling/edema was all anterior the the back of tongue onwards. The soft tissue of the glottic opening was normal but I was already there and didn't want to risk later deterioration and future swelling, so the endotracheal tube went in. It looked like the glottic opening on the right.




That case was a reminder to learn the George Kovacs way of Numbing the Oropharynx.

I didn't have an fiberoptic scope but should have thought of that to intubate through the nose. And if failed try to use an intubating LMA like the LMA protector or air-Q.




Then I looked up the case with my MICU fellow and found this perfect post by REBEL EM.

I wish I had given some FFP to her 2 to 4 units. I don't have the expensive bradykinin receptor blockers. I do have FFP.


I can't make this up. I am glad she survived my learning experience. I more thing to mention to patients when offering them TPA for ischemic stroke. Not just uncorrectable intracranial spontaneous hemorrhage. Now Angioedema.


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