Emergency airway management in a case of lingual haematoma

Point-of-care Ultrasound in Lingual Hematoma

Isolated tongue hematoma following direct trauma to face is not a common finding. It can cause life-threatening airway obstruction and needs prompt diagnosis and early intervention. We report the case of a 40-year-old male who presented to our hospital with a large tongue swelling after a fall. Bedside point-of-care ultrasound (POCUS) of the tongue revealed a hematoma. This case highlights the use of POCUS for early diagnosis of tongue hematomas.

Case report: Traumatic lingual hematoma

We describe a case of traumatic lingual hematoma in a patient on dual antiplatelet therapy. After securing the airway, bilateral lingual artery embolization successfully halted expanding hematoma formation. Patient subsequently required tracheostomy for continued airway edema. Although patient course was wrought with postoperative complications, we review this case to illustrate how prompt hematoma evacuation and embolization can resolve significant vasovagal bradycardia and hypotension secondary to expansile lingual hematoma.

Giant life-threatening external carotid artery pseudoaneurysm caused by a mandibular condylar fracture

OBJECTIVE

Vascular lesions are rare complications associated to mandibular condylar fractures. This paper aims to describe a case of a giant pseudoaneurysm involving the external carotid artery (ECA) caused by a condylar fracture.

CASE REPORT

A 33-year-old man was the victim of traffic accident and presented with a panfacial fracture, including a bilateral condylar fracture. The condylar fracture was treated by closed reduction, and 4 weeks after treatment, the patient developed facial edema, which suggested postoperative infection. An attempt at draining it resulted in intensive bleeding. A computed tomographic angiography showed a huge pseudoaneurysm originating from the ECA. The patient was treated with surgery with ligation of the ECA and drainage of the pseudoaneurysm.

CONCLUSION

Vascular complications associated with condylar fractures are rare, but surgeons should be aware of this type of complication, especially because of the high risk of serious damage, including death. The use of computed tomographic angiography is very helpful in the diagnosis of vascular lesions and also guides treatment.

Life-threatening expansive sublingual hematoma: a stab wound with lingual artery injury

Vascular injuries are a constant risk in facial trauma, although bone and soft tissues of the face have provided some protection to the larger blood vessels. However, penetrating injuries usually do not have this type of protection and can damage significant vascular arteries. This article presents a case of a stab wound, which led to airway obstruction arising to a large sublingual hematoma due to lingual artery injury. A healthy 44-year-old man was stabbed in the submandibular region and admitted with an airway obstruction. He was subjected to an emergency tracheotomy and evolved with progressive sublingual edema. Computed tomography (CT) angiography showed a left lingual artery injury with the formation of an expansive hematoma. The CT angiography findings helped to identify the cause of the hematoma and guided the surgery to drain the hematoma after ligation of the lingual artery. The treatment was safely performed as planned and evolved uneventfully. The patient recovered fast and well and presented normal functions 6 months after the treatment. This surgical technique is an effective method for treating such injuries because it can be safely performed when guided by CT angiography. The authors argue that the demand for vascular lesions should be routine in patients who have facial trauma.

Lingual Haematoma due to Tenecteplase in a Patient with Acute Myocardial Infarction

The use of intravenous thrombolytic agents has revolutionised the treatment of acute myocardial infarction. However, the improvement in mortality rate achieved with these drugs is tempered by the risk of serious bleeding complications, including intracranial haemorrhage. Tenecteplase is a genetically engineered mutant tissue plasminogen activator. Haemorrhagic complications of tissue plasminogen activator (tPA) are well known. Compared to other tPAs, tenecteplase use leads to lower rates of bleeding complications. Here, we report a case of unusual site of spontaneous bleeding, intralingual haematoma during tenecteplase therapy following acute myocardial infarction, which caused significant upper airway obstruction and required tracheotomy to maintain the patient's airway. Clinical dilemmas related to securing the airway or reversing the effects of tissue plasminogen activator are discussed.

Wire-guided (Seldinger technique) intubation through a face mask in urgent, difficult and grossly distorted airways

We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

Lingual Hematoma and Heparin-induced Thrombocytopenia: A Case Report

Lingual hematoma is a rare but potentially fatal cause of upper airway obstruction. Patients receiving anticoagulants such as heparin can suffer from significant complications of these medications. Not only does heparin exert effects directly on the coagulation cascade, but it has the potential to cause thrombocytopenia by stimulating formation of antibodies against platelets. We present the case of a patient being treated with heparin for a deep-vein thrombosis, who subsequently developed heparin-induced thrombocytopenia and lingual hematoma, necessitating tracheotomy.

Lingual hematoma threatening airway obstruction in a patient on oral anticoagulation with warfarin

Warfarin sodium is a commonly used oral anticoagulant agent. It has been well documented that, when effective anticoagulant therapy is employed in treating thromboembolic disease, hemorrhage is a possible complication that can be spontaneous without a history of trauma. The numerous sites of bleeding are the genitourinary and gastrointestinal tracts, the central nervous system, the nose (epistaxis), the penis (priapism), the retroperitoneum, wounds (surgical or traumatic), and subcutaneous tissues during warfarin therapy, but the hemorrhage rarely causes bleeding compromising a patient's airway. We report a case of a spontaneous lingual hematoma that developed during oral anticoagulation therapy. This life-threatening complication of warfarin therapy and its successful management without surgery indicates that observation, close monitoring and reversal of anticoagulation can be a reasonable management option.

Emergency care in facial trauma--a maxillofacial and ophthalmic perspective

Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.

Critical Hemorrhage in the Floor of the Mouth During Implant Placement in the First Mandibular Premolar Position: A Case Report

Although dental implantation is considered to be a safe surgical procedure, this report focuses on a critical hemorrhaging episode associated with implant placement in the first mandibular premolar position. Excessive bleeding and formation of massive lingual, sublingual, and submandibular hematomas were the result of arterial trauma that occurred during the osteotomy preparation. The vascular injury was induced through a perforation of the lingual mandibular cortex. Critical bleeding was conservatively controlled and the case was further handled efficiently with an expectant airway management in a hospital environment. Similar case reports are reviewed in an attempt to draw attention to this rare but potentially life-endangering risk of implant dentistry. Common causes of severe hemorrhage in the floor of the mouth, anatomical considerations, bleeding control measures, and related airway issues are also discussed.

Advanced airway management in the emergency department: what are the training and skills maintenance needs for UK emergency physicians?

This article reviews the evidence for the training of emergency physicians in advanced airway management.