A 49-year-old clinically intoxicated male patient presented to the emergency department (ED) after suffering an assault. Upon initial presentation, he was noted to have a complex upper lip laceration and significant jaw pain suspicious for mandible fracture. During the course of his evaluation, the patient suddenly leapt from the bed and assaulted a medic. He was restrained by multiple security and medical staff with difficulty and given intramuscular haloperidol and ativan for pharmacologic restraint. As he was placed back on the bed, he was noted to be apneic and pulseless. Chest compressions and mask ventilation were initiated, an intraosseous line was placed, and one milligram of epinephrine was administered. On direct laryngoscopy, part of a foreign body was seen coiled around the epiglottis. The complete foreign body was manually removed (image), a 7.5 mm endotracheal tube was placed, and there was prompt return of sinus rhythm and pulses.
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DIAGNOSIS: Hypoxic arrest secondary to airway obstruction with peripheral intravenous (IV) catheter and dressing. Afterward, the assaulted medic reported that prior to being struck, she had witnessed the patient pull out his peripheral IV en masse and shove it in his mouth. Computed tomography scan of the facial bones did verify two mandible fractures, and we surmise that resultant impaired tongue control, neck immobilization from his cervical collar, and gasping during the struggle all contributed to inadvertent aspiration of the IV dressing. The patient was admitted to an ICU, and incurred no neurologic sequelae from his cardiac arrest. To our knowledge, airway obstruction with peripheral IV equipment has not been previously reported in the medical literature. This case highlights the importance of close supervision and repeated assessment of intoxicated patients in the ED.