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Difficulty: HardSurgical and Procedural Interventions

A 5555-year-old man is evaluated in the surgical ward 33 hours after undergoing an anterior cervical discectomy and fusion for severe cervical radiculopathy. The nursing staff requested an urgent evaluation because the patient developed sudden-onset severe anterior neck pressure, difficulty swallowing, and shortness of breath. On arrival, the patient is visibly agitated, diaphoretic, and has audible inspiratory stridor. His temperature is 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), blood pressure is 165/95 mm Hg165/95\text{ mm Hg}, pulse is 118/min118/\text{min}, and respirations are 28/min28/\text{min}. Pulse oximetry shows an oxygen saturation of 87%87\% on room air. Physical examination reveals a tense, rapidly expanding, and ecchymotic swelling beneath the surgical incision on the anterior neck. Which of the following are the most appropriate immediate steps in management? (Select all that apply)

  1. Bedside opening of the surgical incision to evacuate the hematomaAnswer
  2. Preparation for immediate endotracheal intubationAnswer
  3. C
    Urgent computed tomography angiography of the neck
  4. D
    Transfer of the patient to the operating room prior to wound opening
  5. E
    Intravenous administration of high-dose dexamethasone and racemic epinephrine

Answer

The most appropriate immediate steps are bedside opening of the surgical incision to evacuate the hematoma and simultaneous preparation for immediate endotracheal intubation.
The patient is experiencing an expanding neck hematoma, a life-threatening complication of anterior cervical spine surgery (and thyroid or parathyroid surgery) that causes rapid airway compression. The most appropriate immediate steps are to relieve the mechanical compression by opening the surgical incision at the bedside and concurrently preparing to secure the airway via endotracheal intubation. Removing the sutures or clips allows the hematoma to evacuate, which often immediately improves airway patency and venous return. Because airway compromise can progress unpredictably and rapidly, equipment and personnel for immediate endotracheal intubation (and potentially a surgical airway) must be readied simultaneously.

Step-by-Step Solution

1
Identify the primary clinical problem from the presentation.
The patient has an expanding postoperative neck hematoma causing acute mechanical airway compression and impending respiratory failure.
Recognizing the rapidly fatal nature of this complication dictates the urgency of intervention.
2
Determine the most critical therapeutic priorities.
The priorities are immediate relief of the physical compression on the trachea and securing a definitive airway.
Mechanical obstruction requires mechanical decompression; medical management is insufficient.
3
Select the specific interventions that meet these priorities without unnecessary delay.
Bedside wound opening and concurrent preparation for intubation are selected.
Delaying decompression for imaging or transporting an unstable patient risks complete loss of the airway.

Key Concept

Immediate management of a postoperative expanding neck hematoma requires concurrent bedside opening of the surgical wound to relieve mechanical pressure and preparation for definitive airway securement.
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Topics

Surgical and Procedural Interventions

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