Warfarin-Induced Sublingual Hematoma Mimicking Ludwig Angina: Conservative Management of a Potentially Life-Threatening Condition

Cashman, Emma; Shandilya, M.; Amin, Mohammed A.; Hughes, Jane P.; Walsh, Michael J.

doi:10.1177/014556131109000208

Cited by 11 publications

(11 citation statements)

References 11 publications

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“…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.…”

Section: Resultsmentioning

confidence: 99%

“…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.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2015

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Upper airway hematoma (UAH) is a rare but life-threatening complication of oral anticoagulants requiring early recognition. However, no consensus exists regarding the best approach to treatment. We therefore, sought to systematically review the published literature on UAH to elaborate its demographic and clinical characteristics, treatment, complications, and outcomes. A systematic electronic search of PubMed and EMBASE for case reports, case series, and related articles of UAH related to warfarin published from inception (November 1950) to March 2015 was carried out. Categorical variables were expressed as percentage and continuous variables as mean ± standard deviation (SD). Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0. All cases were reported to have UAH as a complication of anticoagulation therapy with warfarin. Demographic and clinical characteristics, treatment, complications and outcomes of UAH were studied. Thirty-eight cases of UAH were identified from 34 reports in the literature. No gender preponderance (male = 52.78%) was seen and the average age of presentation was 60.11 ± 12.50 years. Dysphagia, sore throat, and neck swelling were the most common symptoms and the mean international normalized ratio (INR)at presentation was 8.07 ± 4.04. Most cases had sublingual hematoma (66.57%) followed by retropharyngeal hematoma (27.03%). Of the cases, 48.65% were managed conservatively while the rest underwent either cricothyrotomy or intubation with the time to resolution being 7.69 ± 5.44 days. UAH is a rare butpotentially serious complication of warfarin therapy. It is more common in the elderly population with supratherapeutic INR; inciting events were present in many cases. Overall, it has a good prognosis with significant morbidity present only if concomitant respiratory compromise is present. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise leads to a favorable outcome in most cases.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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

et al. 2015

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“…Medical treatment of overanticoagulation is withholding the drug, parenteral vitamin K and fresh frozen plasma or factor concentrates [ 1 , 2 , 10 ]. Some researchers recommend the use of antibiotics in the treatment of upper airway hematomas because it may be a result of localized infection and vasodilatation [ 1 ] but our patient did not have any symptoms of infection and antibiotics were not necessary.…”

Section: Discussionmentioning

confidence: 99%

Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use

Günaydın¹,

Sivri²,

Sivri

et al. 2015

Case Reports in Emergency Medicine

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Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

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“…Hematoma leading to such obstruction, referred to as “Pseudo–Ludwig’s angina,” is a well-established warfarin-associated phenomenon (including a case report from our own institution). 1 - 9 It has only been documented previously in association with brodifacoum in the veterinary literature. 10…”

Section: Discussionmentioning

confidence: 99%

“…Multiple case reports have described sublingual hematoma secondary to hemorrhage in patients anticoagulated with warfarin. 1 - 9 Sublingual hematoma with airway compromise secondary to brodifacoum, a common long-acting anticoagulant rodenticide, has only been reported in the veterinary literature. 10 A large sublingual hematoma can mimic Ludwig’s angina; either etiology can compromise the airway.…”

Section: Introductionmentioning

confidence: 99%

When Is “Pseudo–Ludwig’s Angina” Associated With Coagulopathy Also a “Pseudo” Hemorrhage?

Lovallo

Patterson

Erickson

et al. 2013

Journal of Investigative Medicine High Impact Case Reports

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Sublingual hematoma secondary to short-acting anticoagulants such as warfarin has been labeled “pseudo–Ludwig’s angina” to distinguish it from the classic syndrome of localized infection and swelling involving the upper airway. Sublingual hematoma with airway compromise secondary to brodifacoum, a common long-acting anticoagulant rodenticide, has only been reported in the veterinary literature. We report a case of massive tongue swelling and impending airway compromise in the context of an intentional long-acting anticoagulant ingestion leading to coagulopathy. The swelling was initially presumed to be due either to infection or hemorrhage, but this was not supported by computed tomography scan imaging. Instead, the patient’s clinical course was consistent with corticosteroid-responsive angioedema, temporally associated with the ingested brodifacoum.

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Warfarin-Induced Sublingual Hematoma Mimicking Ludwig Angina: Conservative Management of a Potentially Life-Threatening Condition

Cited by 11 publications

References 11 publications

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

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

Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use

When Is “Pseudo–Ludwig’s Angina” Associated With Coagulopathy Also a “Pseudo” Hemorrhage?

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