Expanding Neck Hematoma After Total Thyroidectomy
Ms. H is a 45-year-old woman in the PACU 45 minutes after total thyroidectomy for Graves disease. She tells the nurse her neck feels tight. You are called to the bedside and find a 3-cm expanding neck swelling, a hoarse voice, and anxiety. Her SpO2 is 95% on 2 L/min nasal cannula, HR is 118, BP is 160/95, and RR is 28. The surgeon is in another operating room and cannot come immediately. The PACU nurse asks whether to give another dose of IV morphine for pain and anxiety. There is no arterial line, and IV access is a 20-gauge catheter in the right forearm. The emergency airway cart is in the hallway. Her preoperative calcium and PTH were normal.
1. What is the likely cause of deterioration, and what is your priority assessment?
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Expanding neck hematoma with airway compromise is the first concern. The tightness, swelling, hoarseness, anxiety, tachycardia, and rising respiratory rate point to a hematoma compressing the trachea and larynx, not to pain alone. Other possibilities include laryngeal nerve injury, hypocalcemia, and tracheomalacia, but the expanding swelling makes hematoma the immediate threat. My priority assessment is the airway: look for stridor, use of accessory muscles, tracheal deviation, and changes in voice. Monitor SpO2 and mental status continuously. I would not leave the patient to look for the surgeon. I would call for anesthesia and the surgeon, bring the difficult airway cart and code cart, and prepare for emergency decompression. The normal preoperative calcium and PTH make hypocalcemia less likely as the primary cause.
2. Outline your immediate actions and the equipment you need.
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Call for help and activate the rapid response or code team. Sit the patient upright, give high-flow oxygen, and place her on continuous pulse oximetry, ECG, and frequent blood pressure monitoring. Establish a second large-bore IV. Open a suture-removal and decompression kit at the bedside: sterile gloves, suture scissors, hemostats, suction, gauze, and a tracheostomy set. Notify the surgeon and anesthesia immediately. If stridor or severe respiratory distress develops, the wound may need to be opened at the bedside to release the hematoma while preparing for definitive airway management. Do not give additional morphine. It can depress respirations and mask deterioration. Document the time the swelling was first noted, its size, the interventions, and the response.
3. How do you respond to the morphine request, and what do you document and teach?
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I would decline the morphine and explain: 'This is not pain anxiety. It may be an expanding hematoma obstructing her airway. Morphine could suppress her breathing and hide the warning signs.' I would offer reassurance, upright positioning, oxygen, and rapid surgical evaluation instead. I would document the request, my rationale, and the escalation. Postoperatively, I would teach the patient to report neck tightness, difficulty breathing or swallowing, voice changes, and perioral numbness. I would also document the PACU nurse's call, the time the surgeon was notified, and the plan. If the surgeon could not be reached, I would escalate to the on-call surgeon and anesthesia. The RNFA's role is to recognize the emergency, act within protocol, and advocate for the patient.