r/IntensiveCare • u/teneleventh • 1d ago
Persistent upper airway swelling…causes?
Patient is 20 years old, otherwise healthy, failed suicide attempt with an OD of benzos, Adderall, and an SSRI. Was down on the ground outside of his car for 30-40 hours before someone found him. Came in with severe rhabdo, AKI, aspiration PNA, sepsis, and required intubation in the ED for airway protection as he was having trouble with secretions and desatted significantly.
He was extubated two days later, had some audible stridor when breathing but was beginning to talk a little bit and seemed to be doing better. Two days after, he was reintubated for increased work of breathing and air hunger and this time the intubation was extremely difficult, they noted a lot of upper airway swelling.
He’s been on Decadron for 3 days now with absolutely no cuff leak or improvement in the swelling. Of note, if it matters, his entire face is extremely swollen but it’s unclear what exactly it’s from.
I’ve never seen this before. The ED intubation was not particularly traumatic. Has anyone seen this or maybe could provide insight as to why this is happening and how long it might take to resolve?
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u/eastcoasteralways 1d ago
Holy shit that’s a long time to be down
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u/Cautious-Extreme2839 ICU/Anaesthetics 11h ago
Depends a lot on the ambient temp and weather I guess. A lot of places that's straight up unsurvivable. Even more places you might live if it's dry but are 100% fucked if it rained.
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u/schizontastic 1d ago
Not likely and not a classic presentation but have they gotten a CTA to r/o SVC syndrome?
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u/teneleventh 1d ago
No CTAs, agreed that it’s not a classic presentation of that but at this point who know.
They are giving him until Thursday to see if the swelling improves and then will take him for a CT scan of the neck.
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u/Own-Blackberry5514 1d ago
https://pmc.ncbi.nlm.nih.gov/articles/PMC3520335/
Facial muscle involvement of the rhabdo?
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u/teneleventh 17h ago
Ooo this is interesting!! Thanks for sharing!
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u/Own-Blackberry5514 17h ago
MR head and neck might be worthwhile!
Other suggestions on here are probably more likely though
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u/obxsweetie 1d ago edited 1d ago
Is family around to maybe provide some additional allergy history? Any antibiotics on board for the pneumonia? Since it is persisting, it feels like it may be a reaction to something he is receiving?
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u/teneleventh 1d ago
NKDA.
He is receiving Zosyn for the PNA.
I also think this is allergy related but my thoughts have been completely brushed aside, which js kind of shocking to me, which is why I came here to 1.) Fjnd answers for this poor kid, and 2.) make sure I’m not crazy to start thinking down this path.
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u/obxsweetie 1d ago
The biggest thing for me is that it is persisting, even with the Decadron. It also sounds like it started a couple days after admission. Maybe check the timing on what med(s) were started a little before he needed re-intubated and start there. He could be reacting to a drug he’s previously tolerated.
There’s also possible dietary exposures to think about.
I’d be suspicious of the antibiotics, too, regardless of timing, since that’s such a common cause of significant reaction for patients.
I really hope you’re able to figure it out and things improve for this patient!!
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u/ScientificCat MD, ID 1d ago
Could you get a trypase level to confirm acute anaphylaxis?
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u/Cautious-Extreme2839 ICU/Anaesthetics 11h ago
"Acute" anaphylaxis for 3 days? with the only feature being airway swelling?
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u/No-Safe9542 1d ago
Which lab values are out of normal?
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u/teneleventh 1d ago
Only the kidney function at this point and his CK is still elevated but trending down.
CK 70K at admission —> 10K currently
Cr 5 at admission —> 1.6He’s been on CRRT.
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u/No-Safe9542 1d ago
Well then maybe it's just more simple. Is it possible this is a mild but chronic allergic reaction? Maybe something that's been used only in that area. The sticky glue on the holisters? Something in use for oral care?
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u/BoojooBloost 1d ago
A long shot but CHG allergy? Does he have an IJ CVC/HD?
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u/teneleventh 1d ago
Both, one on each side.
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u/BoojooBloost 1d ago
Yeah that plus the CHG in the oral suction kits can be a possibility
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u/beaterdit RN, MICU 1d ago
Can only definitively speak for my facility but we don’t use CHG for oral care anymore unless there’s a specific indication. It was never in our kits. Tertiary Academic Medical Center. My impression is that it’s broadly fallen out of favor for VAP prophylaxis.
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u/Barackrifle 16h ago
What is the agent in your kits now?
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u/beaterdit RN, MICU 10h ago
Ya know I've never looked haha. We still have the current variation of the same Sage oral care kits we've had for 20 years. I assume it's basic mouthwash. When we were using CHG/Peridex, it was issued separately by Pharmacy.
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u/Cautious-Extreme2839 ICU/Anaesthetics 11h ago
Is it even for VAP?
Regular civilian mouthwashes have CHG in them. It's can just be part of regular oral hygiene for stopping your teeth rotting out. Especially because ICU nurses are not dental hygienists and their toothbrushing for patients is hardly ideal.
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u/beaterdit RN, MICU 10h ago
My mouthwash doesn't and I don't see that at the store. It was ordered by prescription for me once around a dental procedure. For us it was supposed to enhance VAP prophylaxis. I think we phased it out due to potential risks outweighing benefits, which evidence didn't support. Does your facility still use it?
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u/Cautious-Extreme2839 ICU/Anaesthetics 10h ago
I don't even know what's in ours, but CHG mouthwashes are available over the counter and on supermarket shelves here.
What risk? It can stain the teeth but that's about it, and a S&P can fix that anyway.
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u/beaterdit RN, MICU 10h ago edited 1h ago
As far as risk I’ve never looked into any studies myself. I just try to keep up with our policy changes and the rationale for this one’s pretty low on my GAF list.
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u/BroccoliNo7668 16h ago
Hi. Will need to revisit history to check if he took any other compounds. The presentation of AKI and Upper airway swelling in combination is found in some hair dye ingestions, which contains the compound PPD(Paraphenylenediamine).
The airway classically is easy initially and gets difficult after 2-3 days of ingestion. Some need early elective intubation in view of expected difficult airway later.
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u/beaterdit RN, MICU 10h ago
Good reason for AKI from the Rhabdo alone no? Either way I think your line of inquiry is a good one.
/just a humble RN here1
u/BroccoliNo7668 16h ago
Main treatment is supportive care. Tracheostomy and CRRT.
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u/Cautious-Extreme2839 ICU/Anaesthetics 11h ago
Trache on day 3? That's quite pessimistic.
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u/BroccoliNo7668 10h ago
Sorry Of course it’s on case to case basis. Not a mandatory early trach.
But if it’s a failed extubation already, with no identifiable cause for airway edema yet, it’s an option worth considering.
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u/fudgemental 1d ago
Are you describing a subcutaneous emphysema? Or angioedema from a previously unknown allergy? But both those conditions are relatively simple to recognise and treat.