Case 61: An Airway Emergency in an Out-of-Hospital Surgical Office

Abstract

Today you find yourself in a free-standing oral surgery office which is 3 miles from the nearest hospital. You are to provide conscious sedation to a 38-year-old man (80 kg and 5′10′′). He is scheduled for a 3-h oral surgery procedure, consisting of multiple dental extractions, alveoloplasty, and placement of multiple dental implants in the mandible. He is otherwise healthy and classified as an ASA 1. The conscious sedation consists of midazolam, ketamine, meperidine, and propofol in multiple divided doses. He is monitored using standard monitoring, including a precordial stethoscope. Supplemental oxygen is provided throughout the procedure via a nasal cannula. After 2.5 h of an uneventful surgical procedure, the surgeon notices a rapidly expanding hematoma in the floor of the mouth as well as a rapid enlargement of the posterior part of the tongue. The patient begins to complain of difficulty in breathing. His oxygen saturation remains in the mid-90s. The surgeon’s attempt to control the bleeding fails. He now believes the reason for the hematomas is an arterial bleed in the floor of the mouth caused by one of the implants. The hematoma continues to expand and the saturation is now falling to 85%. You stop all IV sedation and attempt a blind nasal intubation but that fails. A jaw thrust with a face mask and ventilation with 100% oxygen does not improve the patient’s saturation. Any attempt at an LMA insertion or oral intubation is deemed impossible due to the degree of mechanical obstruction caused by the hematoma.