Help I have an expanding neck hematoma

[VentdependenT]

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Call to floors at midnight by OR charge nurse: "Dr Vent, there is a patient which is an emergency and must come to OR 20 NOW. Neurosurgeon is upstairs wheeling the patient down."

80yr old fella, had an anterior cervical discectomy and fusion, C-5 through T1 ish, earlier today. Neurosurgeon is already wheeling the bed towards the elevator when I meet up.

Pt in no distress. No stridor. A little hoarse but the guy just had surgery. RR in the teens. Speaking full sentences. He can open his mouth fully, tongue midline, uvula looks midline. MP class 2.5 so I can't see it all that well. Big ol purplish neck mass at the surgical site. Trachea looks midline but hell if I know for sure. Its covered by a 6x6 cm swelling hematoma. Surgeon said it is growing before his eyes.

I dont argue. Off to OR's. He wants to pop stitches in the OR and then have me intubate. He is very agreeable to any plan from our standpoint.

What do you wanna do?

 

[coprolalia]

What do you wanna do?

Get the tube in quick!

(So, what happened?)

-copro

 

[Planktonmd]

Call to floors at midnight by OR charge nurse: "Dr Vent, there is a patient which is an emergency and must come to OR 20 NOW. Neurosurgeon is upstairs wheeling the patient down."

80yr old fella, had an anterior cervical discectomy and fusion, C-5 through T1 ish, earlier today. Neurosurgeon is already wheeling the bed towards the elevator when I meet up.

Pt in no distress. No stridor. A little hoarse but the guy just had surgery. RR in the teens. Speaking full sentences. He can open his mouth fully, tongue midline, uvula looks midline. MP class 2.5 so I can't see it all that well. Big ol purplish neck mass at the surgical site. Trachea looks midline but hell if I know for sure. Its covered by a 6x6 cm swelling hematoma. Surgeon said it is growing before his eyes.

I dont argue. Off to OR's. He wants to pop stitches in the OR and then have me intubate. He is very agreeable to any plan from our standpoint.

What do you wanna do?

Let him pop the stitches then induce anesthesia, let someone hold inline immobilization, and intubate (you might want to use a glidescope if you have one), if you have difficulty intubating stick in an LMA and proceed.

 

[johankriek]

awake look,,, awake awake ... fiberoptic..

I would not put him to sleep.. that would be a not so good idea...

 

[Planktonmd]

awake look,,, awake awake ... fiberoptic..

I would not put him to sleep.. that would be a not so good idea...

Patient with no respiratory compromise initially and now the incision is open and the pressure is released, why does he need an awake intubation?

 

[johankriek]

Patient with no respiratory compromise initially and now the incision is open and the pressure is released, why does he need an awake intubation?

if you opened his incision and now feel that his trachea is not deviated and you believe with reasonable certainty that you will be able to intubate him.. then go for it... put him to sleep.. but have a back up plan for when you cant find the trachea....

 

[sensoricaine]

what was the airway exam prior to the surgery? same MP?
does the OR record indicate he was an easy intubation initially?

such a low cervical/thoracic fusion i wouldnt necessarily worry about problems with obtaining good intubating positioning as compared to a higher cervical fusion..although probably have to factor in some degree of post op airway edema..

(side note we had a higher acdf c34 that developed resp distress in pacu 30 mins after extubation that was impossible to intubate, even with attempted oral and nasal fiberoptics b/c the scope could not flex the acute fused angle, eventually ended up with LMA that was left in place for 8-9 hours w/ pt appropriately sedated and then removed in sicu once extubation criteria met and patient fully awake w/ ENT on standby)

its reassuring pt doesnt have any obvious s/s of airway compromise, and really no evidence of pharyngeal bleedingthat would further obstruct view.. if nsgy is going to open the wound then as above poster said, space is decompressed, go ahead put him to sleep and intubate him -provided easy airway initially and have LMA readily avail just in case, theres no real reason why you shouldnt be able ot mask ventilate him if necessary.. i think itd be a bigger deal if you were called to the floor or unit to intubate him w/o the option of having the wound open..

 

[Calilove]

I would consider this patient a Difficult Airway and treat him as such. Patient just had surgery in his neck and an ETT in his throat TODAY... so I would expect edema... and plenty of it. Since this patient is hemodynamically stable and not yet stridorous, I would prepare him for AWAKE fiberoptic intubation. I would expect an abnormal anatomical picture (secondary to hematoma/edema) and have adequate help at bedside for jaw thrust/chin lift/cricoid pressure.

It would be a HUGE mistake to ASSUME that you will be able to intubate this patient after inducing him. If you cannot intubate/ventilate this patient, the surgeon will NOT be able to perform a surgical airway in a timely fashion secondary to all of the above history. By taking away this patient's ability to ventilate, you have put yourself, as well as the surgeon, in a difficult if not IMPOSSIBLE situation.

If this patient has been allowed to eat/drink postoperatively, let's add a full stomach into this picture... which I would assume anyway. No Sedation, Preoxygenate (3 big VC breaths), Glycopyrrolate 0.3 IVP (give it in the hallway prior to coming to OR), Prep for Awake intubation-however u like (i prefer 4% or 5% Lido) (2-3 min.), Fiberoptic instrumentation (20-30 sec.), Confirm placement... This can be performed safely and at times as quickly as rapid sequence intubation, especially if you are skilled with the fiberoptic scope. Preparation time and Fiberoptic instrumentation time MUST be kept to a minimum in order to maintain patient safety.

 

[Planktonmd]

Things can be as complicated and scary as you want them to be in this line of business.
If you are not sure of your abilities no one can blame you for being extra cautious and doing an awake intubation.
But this case does not deserve the level of stress many people are imagining, This is a lower cervical hematoma not causing any compromise of the airway and will be drained before induction of anesthesia!
So, in my humble opinion: once the blood is released the only reason why you would need to intubate awake would be if you felt that mask ventilation and LMA insertion are going to be both impossible for some mysterious reason.

 

[VentdependenT]

Dunno what his prior MP was. Too late for it to make a difference now. Gotta go.

Pt quickly moved to table. Surgeon ready to rock. Splashing prep on neck.

Fentanyl 100 ucg. Versed 2 mg. 4% Lido spray. Ovasapian airway. Fiberoptic. "I see cords." Spray 4% on cords. Scope now through cords. Tube threaded over scope into trachea. +ETCO2 and Condensation. Turn gas on. Surgeon goes to work.

No paralytic needed. Case went fine.

Deep bleeding from muscles around site and at the surface. Put a drain in. Watched for hemostasis.

Surgeon felt that he got excellent control of bleeding. I didn't see anything alarming through the scope. So we extubated the guy. Took him to the Neuro ICU for close monitoring.

Off to C-Section land.