Upper Airway Obstruction Induced by Warfarin Sodium

Abstract

• I report a patient in whom warfarin sodium induced upper airway obstruction secondary to a spontaneous nontraumatic hemorrhage into the sublingual space. Treatment of this obstructive sublingual space hematoma with conservative medical management is reviewed. I discuss the role of warfarin sodium in coagulation and in the production of this pseudo-Ludwig phenomenon.

Isolated sublingual hematoma post internal carotid artery stenting for internal carotid artery stenosis in high-risk patients as uncommon and rare misadventure

“…Bleeding into the sublingual space may elevate the tongue and increase the dead space in the floor of the mouth resulting in a non-infectious life-threatening upper airway obstruction. This picture was first reported in 1976, and known as pseudo-Ludwig's phenomenon [10] , [11] . Sublingual hematoma may be seen in trauma, tongue bite, biopsies at the level of the mouth floor, dental/osseodental procedures, intraoral suturing, or in patients with bleeding disorders.…”

Management of upper airway obstruction secondary to warfarin therapy: the conservative approach

“…Secondly, our case illustrates the importance of establishing a definitive airway. Previous reports do not seem to favour endotracheal intubation, with only two previous successful cases, 6,8 and examples of failed attempts due to obstructive effects of the haematoma. 1,4,5 The introduction of an endotracheal tube carries the risk of causing further haematomas in the larynx.…”

Upper airway hematoma secondary to warfarin therapy: A systematic review of reported cases

“…The mean dose of warfarin taken by the patients was 5.34 ± 2.58 mg. The indications for warfarin were as follows: Mechanical valves (MVs) ( n = 11, 29.73%),[ 2 4 5 6 7 8 9 10 11 ] atrial fibrillation (AF) ( n = 10, 27.03%),[ 3 12 13 14 15 16 17 18 19 20 ] venous thromboembolism (VTE) ( n = 9, 24.32%),[ 1 21 22 23 24 25 26 27 28 ] chronic thrombophlebitis ( n = 2, 5.41%),[ 29 30 ] and polycythemia vera ( n = 1, 2.70%). [ 31 ] The indication of anticoagulation was unclear in four cases.…”

“…Conservative management with vitamin K, fresh frozen plasma (FFP), or prothrombin complex concentrate (PCC) was instituted in 18 (48.65%)[ 2 3 6 8 9 11 12 13 14 15 17 18 19 20 27 32 ] cases Table 2 . Cricothryrotomy was performed in two (5.41%) cases,[ 21 23 ] tracheotomy in 12 (32.43%) cases,[ 1 4 5 11 21 22 23 24 25 26 31 33 ] endotracheal intubation in five (13.51%) cases,[ 1 4 10 22 28 ] nasotracheal intubation in four (10.81%) cases,[ 5 7 16 29 ] and surgical evacuation of hematoma in two (5.41%) cases. [ 4 7 ]…”