A 59-year-old man was admitted to our acute care unit due to persistent intraoral bleeding following extraction of a wisdom tooth. The patient habitually took 20 mg/day of zolpidem, imidazopyridine class of γ-aminobutyric acid A (GABAA) receptor agonist, often taking more than 50 mg/day. Laboratory tests indicated hyponatremia (Na 123 mEq/L, serum osmolality 256 mOsm/L) secondary to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) (ADH 45.3 pg/mL). At the time of admission, he mumbled in delirium and developed generalized tonic seizures twice.
At 11 h after his admission, he vomited approximately 200 mL of clot and blood, and SpO2 decreased to 80%; since aspiration due to intraoral bleeding was suspected, emergency hemostasis and tracheostomy for postoperative respiratory management were performed. Two hours later, SpO2 was 100% with 5 L/min oxygen through the tracheostomy mask. We continuously infused 3% hypertonic saline and administered fosphenytoin and diazepam for treatment of hyponatremia and generalized tonic seizures, respectively. With this treatment, hyponatremia improved and generalized tonic seizures were relieved, while delirium and confusion lasted.
On the second hospital day, he complained of pain in his head and neck together with mild dyspnea (SpO2 95–96% with 2 L/min oxygen). Hemilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema were diagnosed by chest X-ray and CT images of the thorax and neck, for which a chest tube was inserted (Fig. 1). On the seventh hospital day, CT images indicated disappearance of the pneumothorax and remission of subcutaneous emphysema and pneumomediastinum, and the chest tube was removed. On the ninth hospital day, his consciousness and communication normalized and he was discharged on the twelfth hospital day.