An Airway Emergency in an Out of Hospital Surgical Office

Today you find yourself in a freestanding oral surgery office that is 3 miles from the nearest hospital. You are to provide conscious sedation for a 38-yr-old man, (80kg and 5′10″). He is scheduled for a 3-hr 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 American Society of Anesthesiologists physical status 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, attempt a blind nasal intubation, and provide a jaw thrust with a facemask, but no improvement is seen. Any attempt at an laryngeal mask airway insertion or oral intubation is deemed impossible due to the degree of mechanical obstruction caused by the hematoma. What is the most important thing to do now, and what other airway maneuvers can you think of?