Difficult airway with a rapidly expanding neck hematoma after carotid endarterectomy

This is a time-critical, physiologically difficult airway: expanding neck hematoma causing extrinsic compression, distorted anatomy, and a patient who cannot lie flat.

Immediate actions:

1. Call for help-anesthesia attending, additional anesthesia personnel, and the surgeon-and activate the difficult airway algorithm. Do not wait for the surgeon to arrive before preparing.
2. Optimize oxygenation: high-flow nasal oxygen or a tight-fitting mask with CPAP while maintaining an upright or semi-upright position. Do not force the patient supine; she will desaturate and may obstruct completely.
3. Assess the airway: look for stridor, voice change, drooling, and neck swelling. Recognize that this is a "can't intubate, can't ventilate" setup if the hematoma is large.

Airway plan:

• Awake fiberoptic intubation is often the safest approach because it preserves spontaneous ventilation and allows assessment of the distorted airway. However, blood and swelling may obscure the view, and the patient is agitated-topicalization and gentle sedation (e.g., low-dose dexmedetomidine or remifentanil) may be needed.
• Video laryngoscopy is a reasonable alternative if the airway is not completely obstructed and the patient tolerates positioning. Have suction ready for blood.
• If intubation fails and ventilation is inadequate, place a supraglottic airway as a bridge while preparing for a surgical airway.
• A surgical airway (cricothyrotomy or tracheostomy) is indicated if oxygenation cannot be maintained, if intubation fails with a cannot-ventilate picture, or if the hematoma is expanding rapidly. The surgeon should be scrubbed and ready.

Hemodynamics: Control blood pressure with a short-acting agent (e.g., esmolol or nicardipine) to reduce hematoma expansion, but avoid hypotension that could compromise cerebral perfusion in a patient with carotid disease.

Bedside wound opening can decompress the hematoma and convert a critical airway into a manageable one, but it must be coordinated.

Coordination:

• Designate a team leader (usually anesthesia) and assign roles: one person for airway, one for medications, one for suction, one for monitoring, one to assist the surgeon.
• Ensure the surgeon has a sterile field, adequate lighting, suction, and hemostatic agents. Have blood products available if the hematoma is large.
• Position the patient as upright as tolerated; if the wound is opened, the patient may need to lie down, so prepare for rapid airway control.

Equipment ready:

• Difficult airway cart, video laryngoscope, fiberoptic scope, supraglottic airway, cricothyrotomy kit, and a surgeon prepared for tracheostomy.
• Suction with a large-bore catheter, oxygen source, and monitoring (ECG, SpO2, capnography, NIBP or arterial line).

Induction and intubation:

• If the wound is opened and the airway improves, reassess. If the patient is stable and the airway is patent, consider awake fiberoptic intubation or video laryngoscopy.
• If the patient deteriorates, proceed with rapid sequence induction using a hemodynamically neutral agent (e.g., etomidate or ketamine) and rocuronium, with the surgeon ready for immediate tracheostomy. Avoid succinylcholine if there is concern for hyperkalemia or denervation, though it is generally acceptable here.
• Have a plan for cannot-intubate-cannot-ventilate: immediate surgical airway by the surgeon.
• After securing the airway, control blood pressure and investigate the cause of bleeding (e.g., heparin reversal, drain malfunction, surgical hemostasis).