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Zorluk: Çok zorSurgical and Procedural Interventions

A 71-year-old man is evaluated in the surgical intensive care unit three hours after an uncomplicated right carotid endarterectomy. The nursing staff alerts the physician because the patient has become increasingly restless and reports sudden, severe difficulty swallowing along with a sensation of choking. His blood pressure is 185/105 mmHg, pulse is 118/min, and respirations are 26/min. Pulse oximetry shows an oxygen saturation of 92% on a 4-liter nasal cannula. On physical examination, the patient is diaphoretic and in moderate respiratory distress with audible inspiratory stridor. The right neck exhibits a tense, rapidly expanding, plum-colored swelling beneath the closed surgical incision. The trachea is palpably deviated to the left. Which of the following is the most appropriate next step in the management of this patient?

  1. Bedside removal of the surgical wound closure and hematoma evacuationCevap
  2. B
    Endotracheal intubation with rapid sequence induction
  3. C
    Immediate transport to the operating room for wound exploration
  4. D
    Urgent computed tomography angiography of the neck
  5. E
    Intravenous administration of protamine sulfate and nicardipine

Cevap

The correct response is bedside removal of the surgical wound closure and hematoma evacuation.
The patient is presenting with a rapidly expanding neck hematoma after carotid surgery, which has led to acute mechanical airway compression evidenced by stridor and tracheal deviation. The absolute priority is immediate decompression of the airway. This is achieved by promptly cutting the sutures or staples and opening the wound at the bedside to evacuate the hematoma. Once the compressive force is removed, the airway anatomy improves drastically, allowing the patient to breathe or enabling safe intubation if still required, prior to definitive surgical exploration in the operating room.

Adım Adım Çözüm

1
Identify the postoperative complication.
The patient has a rapidly expanding neck hematoma three hours after a carotid endarterectomy.
Recognizing the complication early allows for immediate triage and intervention.
2
Assess the clinical impact and severity of the complication.
The patient exhibits stridor, respiratory distress, and tracheal deviation, indicating imminent loss of the airway.
Airway compromise transforms a surgical complication into an immediate, life-threatening emergency.
3
Determine the safest and most rapid sequence of interventions.
Immediate mechanical decompression of the airway by opening the wound at the bedside is chosen over attempts at intubation or delayed transport.
Opening the wound removes the extrinsic pressure on the trachea, restoring airway patency and allowing for safer subsequent intubation or transport to the operating room.

Anahtar Kavram

Management of Post-Carotid Endarterectomy Expanding Hematoma
Tahmini Süre:1m 30s
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Konular

Surgical and Procedural Interventions

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