nightmare airway . . .

HPI: 63 yof presents with mouth hematoma after undergoing extraction of dental implant.  The patient’s oral surgeon reported no complications and an easy procedure.  She did fine for 2 hours after her extraction, but then had a rapid exanding hematoma form under her tongue.  She is no longer able to handle her secretions.  She denies difficulty breathing through her nose.

PE:
Neck showed submandular edema
Mouth: large sublingual hematoma, pushing the tongue posteriorly and towards the roof of the mouth.  Pt with pooling secretions, minimal active bleeding.

Teaching Points:  Think about the possible problems that can occur in a case like this and plan for them to happen!  To paraphrase Sun Tzu in “The Art of War”—Do not plan for what you think your enemy may do, but rather for what your enemy is capable of doing…

1.  Never underestimate how quickly a sublingual hematoma can ruin your and the patient’s day!
2.  Expanding mouth hematomas are potentially an airway disaster.  Don’t wait too long to act and secure a definitive airway.
3.  Even if you are very good at solving airway problems, know when to call for back-up.
4.  Get ENT to look at the pharynx via a nasal scope.  You can tell a lot about potential airway problems by knowing how they affect posterior structures.
5.  Kaide’s preference for intubating this kind of airway:  Sedation drug of choice–Ketamine–they still breathe!  Paralytics are potentially a problem unless lack of paralysis is making things worse.  #1 Airtraq–if you can see the cords, you can pass the tube since it is directly attached to the end of the airtraq.  #2 Glidescope–may have problems with passing the tube even if you can see the cords.
6.  If you can (based on how quickly things are going bad), get the patient to the OR to have the intubation done via fiber optics.  An ENT surgeon (or other) will be available in the OR to do a formal tracheostomy if needed.
7.  No emergency physician worth anything, will kill this patient if he or she has a 15 blade scalpel, a trach hook (make one by bending the last 1/4 inch of an 18 ga needle to 90° and put it on a syringe) and a 6-0 ETT.
8.  If you must intubate this patient in the ED and you fear a potential failed airway, prep the neck in advance and have all your tools ready!

This patient was taken to the OR and was trached.

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