Code airway. Post-op thyroid. What do you do?

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woopedazz

woopedazz

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I'm wondering what you would all do.

You have just taken a patient off the table in emerg. theatre following I&D of an abscess. You're walking out to consent the lap appendix in holding bay. You get a "Code airway" page to a geries ward.
You get there and find a post-op thyroid patient (5 hours post-op) tripodding in blind panic while a surgical intern is trying to get them to lie flat so they can take a blood pressure.
Sats are 92%, O2 at 15L (code team says he's been above 90% for the past 30 minutes while they've been trying to work out what the problem is... they think it's a PE).
You cut the sutures and no blood comes out, no haematoma is seen. No improvement in patient condition.
You recall that the operating room is currently clean and free. Breast-endo did the thyroid earlier that day and also happen to be the team on call who just did the I&D and are now waiting to do the appendix over in theatres. Their resident wandered over with you to the code airway to make sure it wasn't one of their morning thyroids.

What do you do?

Get started then and there?
Run to theatres?
If in theatre: Are you going to let surgeons cut the neck ASAP? Are you going to sedate/dissociate for the cut? Are you going to induce pre-cut? What drugs will you use? Gas vs IV? Paralysis or no? Fibreoptic or video or direct or other? What are your backup options?


Does knowing any of the following change your decision making:

ASA1 (overweight) patient gets thyroidectomy at midday. Grade 2 view with MAC 3 blade (direct). Good haemostasis at the time.
Slow onset worsening dyspnoea over a period of 4 hours with escelating O2 requirements in the latter 1 hour.
Saturating above 90% on 4L when code called.

Does knowing the slow onset alter your decision making?
 
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Plenty of things you are describing is atypical, the ddx remains broad, and more detail is needed.
- why lay the patient down to get a blood pressure reading? unnecessary.
- PE should be more abrupt, not slowly worsening over a while. still on the ddx, but seems little less likely..
- any hx of asthma or other respiratory conditions?
- other hemodynamics ok? any e/o allergic reaction, angioedema? rash?
- tripoding makes me think some sort of airway obstruction. Is he clearing secretions? stridor? wheeze? tightness?
- you cut neck sutures, so you opened up the surgical site? no obvious hematoma or swelling to neck? what does surgeon think?

Depending on your assessment, you have several options
- If surgeon suspects hematoma AND if you feel patient is stable enough, then go to OR. If unstable, have them open it at bedside without anesthestic. In either case make sure you have all your emergency airway equipment immediately available. Keep HOB up. Would err on the side of avoiding paralytic if possible. Could topicalize and do a look with glidescope.
- If believed to be non-surgical, deal with what you suspect the underlying issue is, whether it is albuterol nebs or treating allergic rxn.
- If you suspect going into respiratory failure due to extreme work of breathing, then plan to intubate whether it is surgical or not.


woopedazz said:
I'm wondering what you would all do.

You have just taken a patient off the table in emerg. theatre following I&D of an abscess. You're walking out to consent the lap appendix in holding bay. You get a "Code airway" page to a geries ward.
You get there and find a post-op thyroid patient (5 hours post-op) tripodding in blind panic while a surgical intern is trying to get them to lie flat so they can take a blood pressure.
Sats are 92%, O2 at 15L (code team says he's been above 90% for the past 30 minutes while they've been trying to work out what the problem is... they think it's a PE).
You cut the sutures and no blood comes out, no haematoma is seen. No improvement in patient condition.
You recall that the operating room is currently clean and free. Breast-endo did the thyroid earlier that day and also happen to be the team on call who just did the I&D and are now waiting to do the appendix over in theatres. Their resident wandered over with you to the code airway to make sure it wasn't one of their morning thyroids.

What do you do?

Get started then and there?
Run to theatres?
If in theatre: Are you going to let surgeons cut the neck ASAP? Are you going to sedate/dissociate for the cut? Are you going to induce pre-cut? What drugs will you use? Gas vs IV? Paralysis or no? Fibreoptic or video or direct or other? What are your backup options?


Does knowing any of the following change your decision making:

ASA1 (overweight) patient gets thyroidectomy at midday. Grade 2 view with MAC 3 blade (direct). Good haemostasis at the time.
Okay in PARU. T/F to ward; eats some lunch.
Surgical ward beds are full so the patient gets T/F to a distant geries ward. He gets a nice comfy room to himself away from the dementia patients so he can rest and recover; here he is cared for by geries nurses and a psych after-hours medical cover intern.
EDITED OUT DETAILS, but basically summary = slow onset worsening dyspnoea over a period of 4 hours with escelating O2 requirements in the latter 1 hour. Surgical cause of subjective dyspnoea not considered.
Saturating above 90% on 4L when code called.

Does knowing the slow onset alter your decision making?
Click to expand...
 
eikenhein said:
no obvious hematoma or swelling to neck? what does surgeon think?
Click to expand...
To keep it from going off topic let's say the surgeon says something along the line of:

"OMG! This is a haematoma deep to the muscle layer. We need to open the whole thing back up again to relieve the pressure, not just the superficial sutures. Are you okay if we do it in theatre? He's saturating above 90% and I'd feel much more comfortable in theatre with our own staff and equipment. Does that sound okay to you? I'll call my boss, he's only 20 minutes away."
 
I have had a very similar experience. Except mine was obvious hematoma after an ACDF. I got there and the patient was literally getting ready to code. Satz were in the 50s and eyes were rolling back in the patient was profusely sweating and tachycardic. Thankfully I was able to intubate with a glidescope and 6 tube. And did not need any medications. And this was after I had asked to ER guy to repeatedly intubate this patient since I was 35 minutes away. And he declined saying that the patient was sitting up and talking in full sentences even after she had almost coded in the CT scanner.

How far is the Getiatric ward? I would err on the side of securing the airway before transporting the patient if the geriatric ward is very far away.

Otherwise of course it’s better to do it in the OR. However the patient may not have 20 minutes. If you are unable to get the airway, the surgical resident needs to get in there and cric or find the obstructing clot, evacuate and help you secure an airway.

Induce sitting up with no paralysis and video laryngoscope with small ETT. There’s no way this patient is going to be able to cooperate for an awake fiber-optic nor is he going to let you just topicalize unless he loses consciousness. Have the OR bring up your difficult airway cart as well as a surgical Cric tray.

Good luck. Ketamine if available.
 
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Awake fiberoptic (at least look), right there right then (or in the OR, whichever is faster, obviously OR is preferable), and page an in-house on-call surgeon stat.

Then you figure out the rest. You could also put an ultrasound on it, but I doubt you can fix the dyspnea at bedside (if you have already opened up the sutures).

No doubt this is surgical. Do not put this patient to sleep unless you have to, or you are sure you can.
 
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woopedazz said:
To keep it from going off topic let's say the surgeon says something along the line of:

"OMG! This is a haematoma deep to the muscle layer. We need to open the whole thing back up again to relieve the pressure, not just the superficial sutures. Are you okay if we do it in theatre? He's saturating above 90% and I'd feel much more comfortable in theatre with our own staff and equipment. Does that sound okay to you? I'll call my boss, he's only 20 minutes away."
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If you have a surgeon available soon, take the patient to the OR fast. Prep the airway while waiting for the surgeon, and intubate awake if you have time (I would push that tube down to the carina). Don't delay the surgery. Have the surgical residents prep the surgical field while waiting.

When the surgeon arrives, if the patient is still unintubated, I would keep the patient sitting as vertically as possible, give ketamine, remi infusion (and local by surgeon), try not inducing/intubating until the surgeon confirms he has the hematoma evacuated. The patient will still need a tube overnight (airway edema), but that will be a safe intubation.

Heliox may also help with respiratory comfort, and may allow the patient to lie down.

I wouldn't intubate asleep unless I have no choice, or the surgeon is at bedside and the neck is prepped to do a trach under the KNOWN level of the hematoma (if I can't pass the tube).
 
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Agree with SaltyDog- hypocalcemia causing VC spasm is high on my differential, and could develop slowly. Other possibilities besides hematoma include anaphylaxis, PTX (esp if surgery was for a larger goiter w/ substernal thyroid tissue), or just good old fashioned airway edema from surgical beating up on the trachea.

Walk into the room, hand goes on the radial pulse, stethoscope goes on the neck. Also call for U/S, either to the room or to the OR depending on destination. Let the OR know we may or may not be coming in hot with a patient so that they can prepare.

Strong pulse, but squeaky breath sounds? Airway obstruction, head to OR for awake vs asleep intubation w/ glide + fiber set up in room, and surgeon with scalpel available to cut when you say go. Empirically push 1g IV CaCl en route to OR. Personally I would do it asleep with ketamine, prop, and sux... but to each their own, as long as you have a bail-out plan. 10 seconds to US the neck first and mark out position of trachea/CTM would be a useful move, if you are familiar with airway US (can also look for presence/size/location of a hematoma).

Normal upper airway sounds but hemodynamic embarrassment? Place art line and send off ABG, get stat CXR and POCUS the chest while XR is en route to r/o tamponade or PTX. Could also listen to the chest for absent breath sounds over one hemothorax, but lung sliding has better sensitivity/specificity for properly trained operators. Depending on the degree of hemodynamic compromise may still need to intubate (even if just to facilitate workup). As long as patient isn’t in extremis and can survive transport to the OR, this intubation is done most safely on an OR bed with all of the toys in the room.

While all of this is going on, would consider giving .15 mg/kg decadron for airway edema if not already given... won’t do you any good in the moment, but you might be doing the ICU a favor a few hrs down the line.
 
I don't see any indication that this is surgical! He did not mention stridor or inability to phonate (so recurrent nerve injury is unlikely) and he also said that there is no swelling of the neck and when he opened the sutures there was no blood!
So all we have is a post-op patient who has progressing dyspnea.
Since the patient is getting agitated and not handling the dyspnea very well I would intubate (Little sedation + Videoscope), and then sedate patient more to make him comfortable.
Then start figuring out the cause of hypoxia (ABG, Calcium level, CXR...)
 
Give this guy some calcium chloride ASAP. It won’t hurt and could help resolve the issue quickly. I would also be thinking pneumo so look for crepitus on exam and consider putting in a chest tube if the patient starts to code. I would get them back to the OR stat and attempt and awake fiberoptic if possible; need surgeon ready for emergent surgical airway. Unlikely to be a PE unless they have some hx of a clotting disorder or other propensity.
 
The only thing I'll add to the ddx above is a zebra, and the time course for this isn't really classic (except on written board exams). If it was a huge or retrosternal thyroid they took out, there may be some tracheomalacia, and the dyspnea may be from dynamic airway collapse with inspiration. CPAP might help acutely.


As an aside, anyone ever give a bolus of calcium to an awake person? It's not fun like dexamethasone; patients don't like it. 🙂
 
pgg said:
The only thing I'll add to the ddx above is a zebra, and the time course for this isn't really classic (except on written board exams). If it was a huge or retrosternal thyroid they took out, there may be some tracheomalacia, and the dyspnea may be from dynamic airway collapse with inspiration. CPAP might help acutely.


As an aside, anyone ever give a bolus of calcium to an awake person? It's not fun like dexamethasone; patients don't like it. 🙂
Click to expand...
What does it do? Make them all warm in the nether-regions? I never have given it awake. However, if in the end it makes them feel overall better, then the temporary discomfort is irrelevant IMO.
 
chocomorsel said:
What does it do? Make them all warm in the nether-regions? I never have given it awake. However, if in the end it makes them feel overall better, then the temporary discomfort is irrelevant IMO.
Click to expand...
I've only bolused it once in an awake person (250 mg flushed in fairly quickly) and have since made a point of not doing it that way again. Now I give it slowly.

He got all wide eyed, opened his mouth like a startled fish, and a few seconds later said he felt his heart start thudding. Then he said "please don't do that again" and I said OK. I'm not sure if it was really uncomfortable or if it just scared him.
 
pgg said:
As an aside, anyone ever give a bolus of calcium to an awake person? It's not fun like dexamethasone; patients don't like it. 🙂
Click to expand...

i haven’t ... what do they complain of? angina???
 
pgg said:
I've only bolused it once in an awake person (250 mg flushed in fairly quickly) and have since made a point of not doing it that way again. Now I give it slowly.

He got all wide eyed, opened his mouth like a startled fish, and a few seconds later said he felt his heart start thudding. Then he said "please don't do that again" and I said OK. I'm not sure if it was really uncomfortable or if it just scared him.
Click to expand...


I wonder if it feels like a CT scan contrast bolus? If you have ever had a CT scan with contrast then you know that warm feeling....like having your privates on a grill. It begins in your genitals and spreads up into your chest and then face. I didn’t know what the hell was going on and I felt like my head was going to explode. It lasts about 30 seconds and then eases. Very unpleasant.
 
Planktonmd said:
I don't see any indication that this is surgical! He did not mention stridor or inability to phonate (so recurrent nerve injury is unlikely) and he also said that there is no swelling of the neck and when he opened the sutures there was no blood!
So all we have is a post-op patient who has progressing dyspnea.
Since the patient is getting agitated and not handling the dyspnea very well I would intubate (Little sedation + Videoscope), and then sedate patient more to make him comfortable.
Then start figuring out the cause of hypoxia (ABG, Calcium level, CXR...)
Click to expand...

yes spontaneously breathing glidescope with either sevo or prop/ketamine/versed
 
JobsFan said:
i haven’t ... what do they complain of? angina???
Click to expand...

I always thought it was burning but then I pushed it through a central line in an unstable patient one night and they went wide-eyed and told me to stop it. They were in hypovolemic shock and obtunded with a belly full of blood but they woke up long enough to swear at me before I induced them. Not sure what they felt but it wasn't good.
 
Deanmonster said:
There are 2 layers of suture. Open the 2nd layer.
Click to expand...

Yeah, so basically this. Combined with a lot of other great stuff other people have said.

Patient has a 'slowly' progressing deep haematoma secondary to a venous bleed, which required the opening of the second layer of sutures; potentially then and there on the geries ward; potentially after being T/F to theatre.

PROGRESS:
They were rapidly transferred to theatre with the surgeon + knife scrubbed and ready on arrival.
The 2nd layer of sutures had not been opened at this stage.
The patient's SpO2 was mid-80s as monitors are applied (on 15L via BVM from the anaesthetic machine).

The decision was made to take a look with a video laryngoscope with some topicalisation and a whiff of propofol.
Following this combination the patient went apnoeic so intubation became paramount. View with the video had deteriorated to a grade 4; bougie could not find its home.
Suxamethonium was pushed and the patient was laid flat to confer optimal view. An alternative blade was attached to the video laryngoscope.
Successfully intubated with a size 6 ETT over bougie.
Sutures were then opened; a deep haematoma extricated.

DISCUSSION:
The issue here is external airway compression; the best way to stabilise the patient is to relieve this external compression.
I would've opened the deep layer of sutures on the ward prior to moving to theatre. Hopefully, that would have attenuated some of the urgency.
- Sit the patient up, open the sutures on the ward, T/F to theatre, BVM 100% O2 +/- heliox, induction dose of ketamine, surgeons cut the neck, suck out the haematoma, stabilise.... THEN tube. That's what I would do in future.
Spontaneous breathing is paramount and any apnoea inducing agents should largely be avoided; including paralytics/propofol/...opioids??
- Reasoning: The patient has a threatened airway and is barely able to maintain patency without medications onboard. Loss of muscle tone will precede airway collapse and complete obstruction.
Fibreoptic may not be the best idea in these cases:
- Reasoning: Severe external airway compression may result in an airway diameter so small that the scope will occlude it.
- Your tube of choice will have to pass over the scope.
- In this case the patient received a ETT 6.0 without enormous resistance, therefore it can be assumed that fibreoptic intubation would have most likely been fine for this patient... however, this wasn't known at the time.
Gaseous induction might be a good idea if you need to tube and there is persistent external compression.
- Reasoning: supports spont. breathing for longer. Less risk of prolonged apnoea. Self-titration in a flailing patient.

But at the end of the day, you've got a threatened airway in a rapidly deteriorating patient who needs a patent airway. Going with what you're comfortable with in the heat of the moment is probably going to confer the best results. I probably would've cut the sutures and induced with ketamine and a video blade... while ****ting my pants.

Thoughts?
 
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“Slow onset worsening dyspnoea over a period of 4 hours with escelating O2 requirements in the latter 1 hour.
Saturating above 90% on 4L when code called.”

This is f’in key,!!
 
woopedazz said:
To keep it from going off topic let's say the surgeon says something along the line of:

"OMG! This is a haematoma deep to the muscle layer. We need to open the whole thing back up again to relieve the pressure, not just the superficial sutures. Are you okay if we do it in theatre? He's saturating above 90% and I'd feel much more comfortable in theatre with our own staff and equipment. Does that sound okay to you? I'll call my boss, he's only 20 minutes away."
Click to expand...
Lmfao
 
“You could also put an ultrasound on it, but I doubt you can fix the dyspnea at bedside (if you have already opened up the sutures).”
Really???
I have never seen an US machine on the floor. And I haven’t seen one arrive in less that a day. Come on dude!you are wasting time and brain cells.
 
Where I work, depending on the floor, getting an US machine is sometimes pretty quick. One more reason to invest in one of the pocket-sized models in my view. Obviously US isn’t the answer for everything (or everyone), but I find it to be a useful adjunct tool in so many situations.

Agree, thanks for the nice case presentation @woopedazz
 
woopedazz said:
and a whiff of propofol.
Following this combination the patient went apnoeic
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I've seen this enough times; if you want to sedate a patient there are a million possibilities but if you want to do an awake procedure do it f. AWAKE.
Let's not pretend that a little of this or a whiff of that will not compromize the airway of a marginal patient
 
Noyac said:
“You could also put an ultrasound on it, but I doubt you can fix the dyspnea at bedside (if you have already opened up the sutures).”
Really???
I have never seen an US machine on the floor. And I haven’t seen one arrive in less that a day. Come on dude!you are wasting time and brain cells.
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This patient was 5 hours post-op. Many times that's in a stepdown-type of observation unit (at least in the US). There may be an ultrasound nearby (or there may be an ICU near a regular ward). Read my posts in their entirety, and you'll see me pleading for not wasting time.
 
woopedazz said:
The decision was made to take a look with a video laryngoscope with some topicalisation and a whiff of propofol.
Following this combination the patient went apnoeic so intubation became paramount. View with the video had deteriorated to a grade 4; bougie could not find its home.
Suxamethonium was pushed and the patient was laid flat to confer optimal view. An alternative blade was attached to the video laryngoscope.
Successfully intubated with a size 6 ETT over bougie.
.

Thoughts?
Click to expand...
Sounds like this got very sketchy ... right up till the tube went in.
All’s well that ends well, I suppose.

Agree with plan to open deep layer of sutures, ENT guy should do this.

I’d put a cannula in his trachea, and feed a wire through it, then preoxygenate and induce with HFNP. Prop, sux, tube w VLS, .
If it goes south - either wire is used for melker or wire out and jet through cannula
 
JobsFan said:
Sounds like this got very sketchy ... right up till the tube went in.
All’s well that ends well, I suppose.

Agree with plan to open deep layer of sutures, ENT guy should do this.

I’d put a cannula in his trachea, and feed a wire through it, then preoxygenate and induce with HFNP. Prop, sux, tube w VLS, .
If it goes south - either wire is used for melker or wire out and jet through cannula
Click to expand...

I did this once. It’s cool on the boards maybe but I’m not sure this is a recipe for success, especially in a Pt with likely deviated anatomy and difficult to assess landmarks. In a normal trachea if you stick the neck and feed a 18-20g cannula in you have to direct cephalad for wire to get thru cords, and even then it’s 1-2cm away (this short distance makes maneuverability difficult). Then if you think you’re gonna jet that has all kinds of potential to make things far worse and make the slowly expanding neck much more acute (especially if you try to manipulate the cannula to try to direct jet caudad).

Like I said, I did this once, in training, with a view of cords via fiber scope and the needle/wire is much closer to cords initially than anticipated. I’m not sure I do this on my own having had that experience.

Otherwise agree with everyone, maintenance of spontaneous ventilation is pivotal.
 
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chocomorsel said:
@woopedazz, once the surgeons saw you struggling, did they step up to open the sutures? I think that should have been the next step as said in my earlier post. Not sit there and watch you struggle with different blades and bougies.
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They were ready to go when needed.
To clarify, this wasn't my case and I wasn't the one with the tube. However, I think it's a good learning case with stuff to discuss.
 
Robotic Wis-Hipple said:
I did this once. It’s cool on the boards maybe but I’m not sure this is a recipe for success, especially in a Pt with likely deviated anatomy and difficult to assess landmarks. In a normal trachea if you stick the neck and feed a 18-20g cannula in you have to direct cephalad for wire to get thru cords, and even then it’s 1-2cm away (this short distance makes maneuverability difficult). Then if you think you’re gonna jet that has all kinds of potential to make things far worse and make the slowly expanding neck much more acute (especially if you try to manipulate the cannula to try to direct jet caudad).

Like I said, I did this once, in training, with a view of cords via fiber scope and the needle/wire is much closer to cords initially than anticipated. I’m not sure I do this on my own having had that experience.

Otherwise agree with everyone, maintenance of spontaneous ventilation is pivotal.
Click to expand...
i’ve done it a few times - in difficult airways. you need to know where the trachea is.

where i’ve had time ive used ultrasound. where i haven’t had time - luckily so far it’s been palpable.

i think it’s a useful technique- it’s quite reassuring knowing you can get O2 in or get a melker in quickly if you need to.
 
Ok, this is me pre-martini. The giveaway was the time since surgery. Ca deficiency is much faster if I recall. Usually it occurs in PACU or shortly afterwards.
So in my experience, having done this exact case twice in my career and once as a an assist to my partner that didn’t heed my warning, you open the incision either on the spot or in the OR if time permits. As soon as the hematoma is evacuated to ask the surgeon to stop for a minute so you can intubate. Then tell him to proceed and fix the bleeder. Take the pt to the unit tubed at least overnight.
Don’t dick around with US on the floor. Don’t draw labs or give a neb. Fix the issue at once.
Does anyone know why I do it this way? Why do I allow evacuation b4 intubation and then intubation b4 control of bleeding?
 
Noyac said:
Ok, this is me pre-martini. The giveaway was the time since surgery. Ca deficiency is much faster if I recall. Usually it occurs in PACU or shortly afterwards.
So in my experience, having done this exact case twice in my career and once as a an assist to my partner that didn’t heed my warning, you open the incision either on the spot or in the OR if time permits. As soon as the hematoma is evacuated to ask the surgeon to stop for a minute so you can intubate. Then tell him to proceed and fix the bleeder. Take the pt to the unit tubed at least overnight.
Don’t dick around with US on the floor. Don’t draw labs or give a neb. Fix the issue at once.
Does anyone know why I do it this way? Why do I allow evacuation b4 intubation and then intubation b4 control of bleeding?
Click to expand...

So I’m pretty sure classic teaching of hypocalcemia induced airway obstruction explains timing being >24hrs out, typically on the floor and not in PACU etc because it’s a devascularization or outright removal of parathyroid glands leading to reduced PTH which takes time to see a reduction in calcium levels.

Recurrent laryngeal injury due to aggressive retraction or surgical injury can cause vocal cord level obstruction much sooner.

So I think hematoma and calcium were both good thoughts here.

And I’ll leave the why evacuate hematoma, then induce/intubate prior to surgical hemostasis to the trainees who want to think it thru.
 
Robotic Wis-Hipple said:
So I’m pretty sure classic teaching of hypocalcemia induced airway obstruction explains timing being >24hrs out, typically on the floor and not in PACU etc because it’s a devascularization or outright removal of parathyroid glands leading to reduced PTH which takes time to see a reduction in calcium levels.

Recurrent laryngeal injury due to aggressive retraction or surgical injury can cause vocal cord level obstruction much sooner.

So I think hematoma and calcium were both good thoughts here.

And I’ll leave the why evacuate hematoma, then induce/intubate prior to surgical hemostasis to the trainees who want to think it thru.
Click to expand...
Fair enough, I remember it being much shorter. But I’m more than a few martinis into this evening so I will only state what I recall clearly.
If it is a Ca issue, what is your treatment?
If it’s a hematoma issue, what is your treatment?
Which one will be more difficult to deal with?
Which one will have you watching the pt die in front of your face?
In my differential, the first 3 are hematoma. And this is the one that will kill this pt right in front of you. Ca depletion is easily resolved. Even if you have to intubate and figure it out later.
So back to my previous post, why do “I” choose to allow exploration and then stop. to intubate and then proceed with the surgery?
 
Noyac said:
So back to my previous post, why do “I” choose to allow exploration and then stop. to intubate and then proceed with the surgery?
Click to expand...
I'm not sure if I'm right (even though I wrote it earlier like I knew what I was talking about), but what I said earlier was:
The issue here is external airway compression; the best way to stabilise the patient is to relieve this external compression - this enables you to maintain spontaneous breathing without the addition of intubating medications which will obtund spont. breathing and potentially lead to complete loss of airway.
Relieving the external compression has the added benefit of giving you optimal intubating conditions: more time, better view, potential to pass a fibreoptic without occluding the narrowed airway, etc.

I presume you stop them and intubate once the haematoma has been extricated, because we are operating around the trachea and we would very much like a secured airway with reduced risk of laryngospasm/other nasties and it also allows us to take a step back and let the surgeons operate in whatever weird and wonderful (and draped) position they would like for optimal surgical result.
Plus they need a tube anyway, may as well put it in before more swelling/haematoma develops.

EDIT: Oh, and NIM tube... might be particularly useful here.

Right or wrong?
 
Presumably neuromonitoring decreases the risk of temporary or permanent injury to the RLN. At my institution it is considered a "standard of care", although whether it actually improves outcomes is still debated.

link.springer.com

Intraoperative Neuromonitoring in Thyroid Surgery: A Systematic Review - World Journal of Surgery

This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery. When IONM results in false positives, it seeks to evaluate contributing factors. A systematic review was conducted gauging the...
link.springer.com link.springer.com
jamanetwork.com

Intraoperative Neuromonitoring and Reduced RLN Injury in Total Thyroidectomy

This cohort study compares the incidence of recurrent laryngeal nerve injury in total thyroidectomy patients who had intraoperative neuromonitoring vs those who had nerve visualization alone.
jamanetwork.com jamanetwork.com
 
woopedazz said:
I'm not sure if I'm right (even though I wrote it earlier like I knew what I was talking about), but what I said earlier was:
The issue here is external airway compression; the best way to stabilise the patient is to relieve this external compression - this enables you to maintain spontaneous breathing without the addition of intubating medications which will obtund spont. breathing and potentially lead to complete loss of airway.
Relieving the external compression has the added benefit of giving you optimal intubating conditions: more time, better view, potential to pass a fibreoptic without occluding the narrowed airway, etc.

I presume you stop them and intubate once the haematoma has been extricated, because we are operating around the trachea and we would very much like a secured airway with reduced risk of laryngospasm/other nasties and it also allows us to take a step back and let the surgeons operate in whatever weird and wonderful (and draped) position they would like for optimal surgical result.
Plus they need a tube anyway, may as well put it in before more swelling/haematoma develops.

EDIT: Oh, and NIM tube... might be particularly useful here.

Right or wrong?
Click to expand...
Fantastic!
Yes I want the hematoma evacuated because it is putting pressure on the airway leading to tracheal deviation and swelling. This pt is maintaining his stats above 90% even if it is for only a few more minutes. Maintaining spontaneous ventilation is a huge advantage. Once the hematoma has been evacuated then the airway becomes more manageable even with a direct laryngoscopy. I love the 16-18g Iv cath placed in the trachea for jet ventilation or even connecting to the circuit via a 3cc syringe and closed APL valve. But I understand people’s hesitation here. All you need to do is use a quick finder needle if you are not certain of the tracheal location. Aspirate air and you are golden.
But the main reason for intubating after evacuation is because the process of removing the clot and addressing the bleeder will lead to severe edema and respiratory compromise even worse than the current state. You will think all is well as the pt begins to move more air after the evacuation but this is only temporary. Always always intubate these pts and send them to the unit for the evening or more.
 
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