A nurse urgently calls the on-duty physician to the post-anesthesia care unit to evaluate a patient who underwent an uncomplicated total thyroidectomy for a multinodular goiter three hours ago. The patient is a 48-year-old female who is now exhibiting severe agitation, high-pitched inspiratory stridor, and progressive dyspnea. Her oxygen saturation is 86% on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the surgical incision on her anterior neck. Which of the following procedural and management steps are indicated IMMEDIATELY for this patient? (Select all that apply)
- Bedside removal of surgical sutures or clips to open the incision and evacuate the hematomaCevap
- Preparation for emergent endotracheal intubation or surgical airway placementCevap
- CImmediate transfer to the operating room for initial wound exploration under general anesthesia
- DApplication of a firm compressive pressure dressing over the anterior neck to tamponade bleeding
- EComputed tomography imaging of the soft tissues of the neck to define the extent of the hematoma
Cevap
The immediate indicated steps are bedside removal of surgical sutures to evacuate the hematoma and concurrent preparation for emergent endotracheal intubation.
The patient is experiencing a rapidly expanding neck hematoma, a recognized and life-threatening complication following thyroid or parathyroid surgery. The accumulating hematoma causes extrinsic compression of the trachea and impairs venous return, rapidly leading to stridor, hypoxia, and impending airway collapse. The absolute highest priority is immediate bedside decompression. This is achieved by removing the surgical sutures or clips and digitally opening the incision to evacuate the clot and relieve pressure on the airway. Concurrently, the clinical team must prepare for emergent endotracheal intubation or a surgical airway (cricothyroidotomy). Even with successful decompression, the airway may remain compromised due to laryngeal edema, tracheal malacia, or continued brisk bleeding, necessitating a definitive airway. Only after the airway is secured and the hematoma is initially decompressed at the bedside should the patient be transferred to the operating room for formal surgical hemostasis under sterile conditions.
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Anahtar Kavram
Management of life-threatening post-operative neck hematomas requires immediate bedside surgical decompression and concurrent preparation for definitive airway management.