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Fatal upper airway obstruction induced by superior mediastinum bleeding

      To the Editor:—Cervical hematoma is one of the causes of upper airway obstruction.
      • Munro F.J
      • Makin A.P
      • Reid J
      Airway problems after carotid endarterectomy.
      ,
      • Holdsworth R.J
      • McCollum P.T
      Acute laryngeal oedema following carotid endarterectomy.
      ,
      • Digby S
      Fatal respiratory obstruction following insertion of a central venous line.
      ,
      • Randalls B
      • Toomey P.J
      Laryngeal oedema from a neck haematoma. A complication of internal jugular vein cannulation.
      ,
      • Lo W.K
      • Chong J.L
      Neck haematoma and airway obstruction in a pre-eclamptic patient A complication of internal jugular vein cannulation.
      We report a case of fatal upper airway obstruction possibly caused by aortic arch rupture—induced cervical internal hemorrhage.
      Sudden cardiac arrest occurred in a 63-year-old man while undergoing body massotherapy in the prone position. After short-term stridor, he lost consciousness. Rapid swelling of the neck was observed. Bystander cardiopulmonary resuscitation (CPR), including mouth-to-mouth ventilation and cardiac massage, was immediately started. Nine minutes later, life-saving technicians took over CPR. No obstructing substance was found in his oral space. Ventilation through an inserted combitube airway was impossible. Pulseless electric activity on an electrocardiogram (ECG) was confirmed.
      At 22 minutes after the start of CPR, the patient arrived at our emergency room (Glasgow Coma Scale: 3, pulseless electric activity on ECG). Epinephrine (1 mg intravenously) increased the heart rate on ECG from 35 to 65/min but did not increase blood pressure. Because ventilation was still impossible, the combitube airway was removed. Subsequent laryngoscopy was extremely difficult; the supraglottic and glottic areas were filled with mucosal edema and blocked by an upheaved pharyngeal posterior wall, making discrimination of the epiglottis, arytenoids cartilage, and vocal cords impossible. In contrast, no significant edema was seen in oral, nasal, and conjunctival mucosae. Immediate cricothyrotomy was executed, and control ventilation then became possible with no respiratory deficiency (results of blood gas analysis: Pao2, 87.1 mm Hg; Paco2, 27.7 mm Hg; pH, 6.925; base excess, −24.0 at 10 min after the resumption of ventilation). Intravenous administration of 150 mL of 7% NaHCO3 and 2 mg epinephrine after resumption of ventilation improved circulation (arterial blood pressure, 66/42 mm Hg; heart rate, 141/min). Thereafter, dopamine (15 μg/kg/min) was intravenously administrated to maintain blood pressure.
      Dilation of the upper mediastinum was seen in a radiograph (Fig 1). The patient’s swollen neck was strained. Cervical echograms showed bilateral, irregular-shaped, low-echo areas with unclear outlines around the internal carotid arteries. Internal juglar veins, which should appear near the internal carotid arteries, could not be discriminated in echograms (Fig 2). Inspection with a bronchofiber showed apparently normal tracheal mucosa and cartilage but a greatly upheaved tracheal membranous portion. No hemothorax was found in echograms or radiographs.
      Figure thumbnail GR1
      FIGURE 1Chest radiograph showing dilated upper mediastinum.
      Figure thumbnail GR2
      FIGURE 2Cervical echogram showing low-echo area with an unclear outline around the right carotid artery. The right internal juglar vein, which should appear near the carotid artery, could not be discriminated. a, Low-echo area; b, internal carotid artery; c, sternocleidomastoid muscle.
      Neurologic recovery was not achieved. Dopamine administration failed to maintain blood pressure and heart rate, and the circulation thus gradually deteriorated. The patient died about 115 minutes after the start of CPR. A postmortem inquest using a laryngofiber revealed that the mucosal edema and upheaval of the posterior wall in the pharynx had been reduced but still remained.
      Diagnosis of the cause of upper-airway obstruction in this case while executing CPR was difficult. Allergic reaction was not thought to have been the cause because oral, nasal, conjunctival, and tracheal mucosae were not edematous and no other allergic symptoms were found. We suspected cervical space occupying lesions (SOLs) shown by the bilaterally expanded cervical low-echo areas to be the cause of the airway obstruction. Compression of the bilateral internal juglar veins by the SOLs might have caused deterioration in local circulation and then elicited the severe mucosal edema, and the SOLs might also have directly caused upheaval of the pharyngeal posterior wall. The synchronized onset of respiratory distress and cervical swelling supports this hypothesis regarding the cause. The cervical swelling was rapid and seemed to be increasing tissue pressure. The compressed internal juglar veins, upheaved pharyngeal posterior wall, and upheaved tracheal membrane portion indicate increase in pressure of cervical and peritracheal tissue. The upper mediastinum was dilated. These findings suggested that the SOL was most likely to be an arterial hemorrhage—induced hematoma spreading in the upper mediastinum and bilateral cervical area. We also considered tumor and inflammation as the possible contents of the SOLs; however, these could not explain the very rapid onset of upper-airway obstruction. Bilaterality of the cervical hematomas strongly suggests that a bleeding point did not exist on 1 side of the internal carotid arteries. We strongly suspect that the bleeding point existed in the dilated upper mediastinum, most likely at the top of the aortic arch where the carotid arteries originate. Acute upper-airway obstruction after accidental puncture of the internal carotid artery has been reported,
      • Digby S
      Fatal respiratory obstruction following insertion of a central venous line.
      ,
      • Randalls B
      • Toomey P.J
      Laryngeal oedema from a neck haematoma. A complication of internal jugular vein cannulation.
      ,
      • Lo W.K
      • Chong J.L
      Neck haematoma and airway obstruction in a pre-eclamptic patient A complication of internal jugular vein cannulation.
      but, we have found no other reports of upper airway obstruction induced by superior mediastinum bleeding. Aortic arch rupture in the superior mediastinum should be regarded as one of the mechanisms eliciting acute upper-airway obstruction.

      References

        • Munro F.J
        • Makin A.P
        • Reid J
        Airway problems after carotid endarterectomy.
        Br J Anaesth. 1996; 76: 156-159
        • Holdsworth R.J
        • McCollum P.T
        Acute laryngeal oedema following carotid endarterectomy.
        J Cardiovasc Surg. 1994; 35: 249-251
        • Digby S
        Fatal respiratory obstruction following insertion of a central venous line.
        Anaesthesia. 1994; 49: 1013-1014
        • Randalls B
        • Toomey P.J
        Laryngeal oedema from a neck haematoma. A complication of internal jugular vein cannulation.
        Anaesthesia. 1990; 45: 850-852
        • Lo W.K
        • Chong J.L
        Neck haematoma and airway obstruction in a pre-eclamptic patient.
        Anaesth Intensive Care. 1997; 25: 423-425