Expanding Neck Hematoma
Considerations
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Emergency situation with little or no time to optimize
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Anatomical airway distortion & edema resulting in a difficult airway:
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Systematic & multidisciplinary approach critical, double set-up is key!
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Release of sutures & evacuation of hematoma may be life-saving & may eliminate the need for a crash intubation
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Unless impossible, spontaneous ventilation should be maintained & awake fiberoptic intubation attempted in the OR
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Direct laryngoscopy (awake or anesthesized) is an option & should be part of the management algorithm
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Potentially full stomach & risk of aspiration in cases of delayed hematoma formation
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Medical & surgical control of hematoma once patient stabilized:
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Likely need for return to OR for neck exploration
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Possible need to reverse coagulopathy, thrombocytopenia, platelet dysfunction
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Theoretical potential for hemodynamic instability due to compression of carotid sinus with resulting bradycardia/hypotension
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Simultaneous management of medical comorbidities:
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E.g. coronary artery disease in carotid endartarectomy patients
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Goals
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Immediate assessment & decisive airway plan
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Safe airway management preserving spontaneous ventilation, upper airway tone & patient cooperation
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Temporize as necessary to maintain airway patency
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Always have surgical backups prepared
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Conservative & cautious extubation strategy
Conflicts
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Uncooperative, agitated patient requiring an awake technique
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Emergency airway management required in an out of OR setting