Expanding Neck Hematoma After Carotid Endarterectomy

This is a postoperative neck hematoma causing progressive airway obstruction, not an airway that can wait for a scope to be fetched.

Next 10 minutes:

1. Call for help: surgeon, second anesthesiologist, difficult-airway cart, and blood. Do not leave the bedside.
2. Sit him upright, give 100% oxygen by a tight-fitting mask, and monitor continuously.
3. Get the surgeon to open the wound and evacuate the hematoma at the bedside now. Decompression can relieve the obstruction before any instrument touches the airway.
4. Prepare for intubation and for a surgical airway: videolaryngoscope, smaller tubes, suction, and the surgeon scrubbed and ready to perform a tracheostomy or cricothyrotomy.
5. Control blood pressure (labetalol or nicardipine) and reverse heparin with protamine if bleeding continues, weighing this against carotid thrombosis risk.

What not to do: Do not sedate him further, do not lie him flat, and do not send him for imaging. An awake fiberoptic intubation is a poor first choice here: the anatomy is distorted by blood and edema, topicalization may provoke coughing and further bleeding, and cooperation may deteriorate quickly. The priority is decompression with the airway team and the surgeon both ready.

Awake fiberoptic: Preserves spontaneous ventilation, but requires cooperation, adequate topicalization, and a viewable airway. Blood, edema, and a compressed pharynx may render the view useless, and the procedure takes time he may not have. It is a reasonable option only after wound decompression if he is stable and cooperative.

Video laryngoscopy after induction: Provides a rapid, high-quality view and allows rescue with a supraglottic airway. The hazard is loss of the airway after induction, so it must be done with the surgeon in the room and prepared for an immediate surgical airway, and with a plan for a reduced-dose induction that preserves hemodynamics.

Surgical airway: Reliable but difficult here: the neck is swollen and distorted by hematoma, and landmarks are obscured. It is the rescue, not the first step, unless complete obstruction occurs.

Decision drivers:

• Airway after decompression: if stridor improves and the anatomy is clearer, an inhalational or awake technique becomes safer
• Rate of deterioration and ability to oxygenate
• Surgeon readiness for tracheostomy
• Hemodynamics and carotid perfusion

My sequence would be: decompress first, then reassess; if obstruction persists, an inhalational induction with spontaneous ventilation or awake fiberoptic with surgical backup; if obstruction is imminent, an immediate surgical airway.

Clinical:

• Keep the patient intubated and sedated if significant laryngeal or pharyngeal edema is likely; perform a leak test and extubate only when the airway is demonstrably safe, with steroids and reintubation equipment available
• ICU admission with continuous monitoring, a functioning drain, and frequent neck inspection
• Balance heparin/protamine against carotid thrombosis; discuss with the surgeon and consider duplex imaging
• Strict blood pressure control to prevent rebleeding
• Watch for cranial nerve injury and for airway obstruction from recurrent swelling

Systems and quality:

• Review the PACU handoff and monitoring interval: was the swelling identified early enough?
• Debrief with surgery on the anticoagulation strategy and drain use
• Ensure a difficult-airway cart, a surgeon capable of an emergency airway, and a clearly written escalation pathway are immediately available on the vascular ward
• Document the event and complete an incident report if there was a delay in decompression
• If recurrent hematomas cluster, review the reversal protocol and postoperative BP targets as a department