P037: AIRWAY MANAGEMENT IN THE SETTING OF AN EXPANDING NECK HEMATOMA
Sharlene A Lobo, MD, Reena John, DO, Guillermo Velasquez, MD; Aventura Hospital and Medical Center
Background: The patient was a 71 year old obese male with a past medical history of hypertension, benign prostatic hyperplasia and multinodular toxic goiter, for which he underwent a total thyroidectomy. In the recovery room, he began to develop dyspnea and an expanding neck hematoma was noted. He was then emergently taken back to the operating room for evacuation of the hematoma. During the procedure, multiple attempts at intubation and ventilation took place with the eventual placement of a surgical airway.
Methods/Results: With progressively worsening dyspnea, the patient was placed on a non-rebreather mask and taken to the operating room. He was pre-oxygenated, and an etO2 of 92% was achieved. He was then positioned to optimize intubation and a rapid sequence induction was performed. Immediately following induction and fasciculations, a glidescope was inserted and the patient’s vocal cords were completely visualized. The vocal cords appeared closed despite paralysis and the surrounding supraglottic structures were grossly edematous and inflamed. Multiple unsuccessful attempts were made to pass an endotracheal tube of varying sizes, starting with 7.5 down to 5.5. At this point, the patient began to desaturate and attempts at mask ventilation were unsuccessful. Finally, ventilation was achieved with placement of a 4.0 LMA, and spontaneous respiration resumed. Fiberoptic intubation was attempted through the LMA with complete visualization of severely swollen vocal cords, without success. It was then decided to create a tracheostomy to prevent impending respiratory failure post-operatively.
Discussion: Development of a hematoma following a thyroidectomy is a rare and potentially lethal complication. Risk factors include: male sex, higher age, obesity, type of surgery (partial vs total thyroidectomy), neck dissection, use of antithrombotic agents and intraoperative blood transfusion. Airway management in this case appropriately followed the difficult airway algorithm. In retrospect, initial attempts at intubation could have been performed without paralysis, as this could have caused total airway collapse.