Expanding Neck Hematoma Management

Neck hematomas are a life threatening albeit rare post operative complication of surgeries in the cervical spine and neck (thyroidectomy, carotid endarterectomy, etc.) The overwhelming majority of patients who undergo these types of surgeries recover in the post-anesthesia care unit (PACU) and go home after meeting discharge criteria. 

Neck anatomy (Image: Wikimedia Commons)

A textbook vignette anesthesiologists must always consider is an expanding neck hematoma causing upper airway obstruction. From an airway standpoint, these patients are very challenging to mask ventilate and intubate. Performing an emergent tracheostomy is also difficult since surface landmarks are obliterated by the tense hematoma, and bleeding is ongoing.

The typical airway-breathing-circulation (ABC) approach to a deteriorating patient is also unhelpful in these situations. Short of extending the neck (limited due to the hematoma) and providing supplemental oxygen, the inherent concern in this situation DEALS with the airway and breathing. Couple that with growing patient anxiety, and the whole situation can quickly spiral downward.

So how should we intervene in these situations?

  • Rapidly assess the situation and keep the patient calm! Tell them who you are and survey the surrounding area. You don’t need 50 unfamiliar people staring at the patient with varying levels of concern on their faces. I have a VERY low threshold to politely send nonessential people away.
  • Provide supplemental oxygen while optimizing respiratory mechanics (sit the patient up, extend the neck, etc.)
  • Mobilize help. Call for the anesthesiologist and surgeons STAT overhead. Have a tech bring airway equipment to the bedside while also calling for an operating room. Waste no time in getting the patient to the O.R.!

Many texts refer to cutting the sutures to relieve the hematoma. An expanding neck hematoma might cause tracheal deviation but should not overtly squish the trachea shut due to its rigid cartilaginous ring architecture. These patients have soft tissue swelling due to venous engorgement. Even if you drain the hematoma, edema will persist for many hours, so the airway will still remain tenuous. In my opinion, these airways need to be secured in the operating room. 

  • After arriving to the operating room, have the surgeons gowned and ready to perform a tracheostomy. Splash sterile prep on the neck.
  • Perform an awake fiberoptic intubation in the upright position with supplemental oxygen provided by nasal cannula. I wrote about my technique in a previous post. Use a smaller endotracheal tube than you normally would with plenty of topicalization if time permits. Also consider the nasal route!
  • After the airway is secure, induce general anesthesia with a combination of IV hypnotics and volatile agents. These patients should remain intubated, observed carefully over 12-24 hours and checked for a cuff leak prior to extubation. It’s important to communicate this with all disciplines involved in the patient’s care (ICU team, respiratory therapy, nursing).

Drop me a comment below with questions!

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  1. Hello Rishi, how do you perform cuff leak tests in practice and the what is the threshold upon which a cuff leak test is postive? Thanks and best of luck for what’s to come

    • I suction the endotracheal tube and oropharynx, adjust the FiO2 to 0.8 (in anticipation for extubation and to mitigate absorption atelectasis), and place the patient in a volume control mode. After deflating the endotracheal tube cuff, I listen for an obvious leak and make sure there’s a cuff leak volume – the difference between the preset tidal volume on the ventilator and the patient’s expiratory tidal volume. Our respiratory therapists will routinely do cuff leak tests in the ICU, but if I’m concerned about extubating a patient after a long surgery, I’ll do it myself in the operating room. 🙂


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