Expanding Neck Hematoma

 

 

Considerations

 

  • Emergency situation with little or no time to optimize

  • Anatomical airway distortion & edema resulting in a difficult airway:

    • Systematic & multidisciplinary approach critical, double set-up is key!

    • Release of sutures & evacuation of hematoma may be life-saving & may eliminate the need for a crash intubation

    • Unless impossible, spontaneous ventilation should be maintained & awake fiberoptic intubation attempted in the OR

    • Direct laryngoscopy (awake or anesthesized) is an option & should be part of the management algorithm

  • Potentially full stomach & risk of aspiration in cases of delayed hematoma formation

  • Medical & surgical control of hematoma once patient stabilized:

    • Likely need for return to OR for neck exploration

    • Possible need to reverse coagulopathy, thrombocytopenia, platelet dysfunction

  • Theoretical potential for hemodynamic instability due to compression of carotid sinus with resulting bradycardia/hypotension

  • Simultaneous management of medical comorbidities:

    • E.g. coronary artery disease in carotid endartarectomy patients 

 

 

Goals

 

  • Immediate assessment & decisive airway plan

  • Safe airway management preserving spontaneous ventilation, upper airway tone & patient cooperation

  • Temporize as necessary to maintain airway patency

  • Always have surgical backups prepared 

  • Conservative & cautious extubation strategy

 

 

Conflicts

 

  • Uncooperative, agitated patient requiring an awake technique

  • Emergency airway management required in an out of OR setting