Beware of upper airway obstruction in warfarinized patients
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The following case has been published in the Journal of Anaesthesiology Clinical Pharmacology.

An 86-year-old woman was admitted under the care of the medical team and treated for a community-acquired pneumonia and pulmonary edema. On day 3 of her admission, she was noted to have malar, chin, and submental ecchymosis. Within 24 h, it was noted that she was in respiratory distress with clearly audible stertor and a subtle inspiratory stridor. Her respiratory rate was noted to have increased and her oxygen saturations dropped from 96% to 90% on room air.

This was accompanied by significant chin, submental, neck, and upper chest ecchymosis. Oral examination revealed a swollen and purple tongue and floor of mouth, consistent with lingual and sublingual hamatomas. Flexible nasoendoscopy revealed diffuse submucosal supraglottic hematoma with a narrowed laryngeal inlet. Blood screening demonstrated an international normalized ratio of 4 and a stable hemoglobin and platelet count.

Initial management included nursing the patient upright and administration of oxygen through a non-rebreath mask, at a flow rate of 15 L/min. Intravenous vitamin K was administered immediately. After a hematology consult, four-factor prothrombin complex concentrate was administered as a rapid reversal of anticoagulation.

Once stabilized, she was transferred to theater for fibreoptic intubation, with an ENT team available to establish a surgical airway. The patient was successfully intubated through the oral route and was transferred to the ICU for further support. Subsequently respiratory failure after 24 h of ventilation in the ICU led to unfortunate demise of the patient.

- Patients on a coumarin are at risk of spontaneous upper airway obstruction secondary to hematoma if anticoagulation is poorly controlled.

- Treatment in these instances needs to be prompt and includes medical, anesthetic, and potentially surgical intervention.

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