26
General Supportive Early Management
Table 4. Management of Orolingual Angioedema Associated
With IV Thrombolytic Administration for AIS in Adults
Maintain airway
Endotracheal intubation may not be necessary if edema is limited to the anterior tongue
and lips.
Edema involving the larynx, palate, floor of mouth, or oropharynx with rapid
progression (within 30 min) poses a higher risk of requiring intubation.
Awake fiberoptic intubation is optimal. Nasal-tracheal intubation may be required but
poses risk of epistaxis aer IV thrombolytic use. Cricothyroidotomy is rarely needed and
also problematic aer IV thrombolytic use.
Discontinue IV thrombolytic infusion (if alteplase) and hold ACE inhibitors.
Administer IV methylprednisolone 125 mg.
Administer IV diphenhydramine 50 mg.
Administer ranitidine 50 mg IV or famotidine 20 mg IV.
If there is further increase in angioedema, administer 0.1% epinephrine (1 mg/mL
concentration) 0.3 mL subcutaneously or by nebulizer 0.5 mg/dL.
Icatibant, a selective bradykinin B2 receptor antagonist, 3 mL (30 mg ) subcutaneously
in abdominal area; additional injection of 30 mg may be administered at intervals of
6 h not to exceed a total of 3 injections in 24 h; and plasma-derived C1 esterase
inhibitor (20 IU/kg ) has been successfully used in hereditary angioedema and ACE
inhibitor-related angioedema.
Provide supportive care.
Adapted with permission from Sloan et al, Mahaffey et al, Goldstein et al, French et al, Yaghi
et al, Stone et al, and Frontera et al.
ACE indicates angiotensin-converting enzyme; AIS, acute ischemic stroke; COR, class of
recommendation; IV, intravenous; and LOE, level of evidence.
4.6.2. Choice of Thrombolytic Agent
COR LOE
Recommendations
1 A
1. (New and of High Impact) In adult patients with AIS
presenting within 4.5 hours of symptom onset or last known
well and eligible for IVT, tenecteplase at a dose of 0.25 mg/kg
body weight (max 25 mg ) or alteplase at a dose of 0.9 mg/kg
body weight is recommended to improve functional outcomes.
3: No
benefit
A
2. In adult patients with AIS presenting within 4.5 hours of
symptom onset or last known well and eligible for IVT,
tenecteplase at a dose of 0.4 mg/kg body weight is not
recommended.
