Post-operative neck haemorrhage from thyroid/carotid/neuro/ear nose throat surgery

Theory

This is a dramatic and sudden threat to life.

Problems stem from the need to establish a patent airway and the effect neck haemorrhage has on the patient’s airway.

Although an expanding haematoma in the neck can directly compress the trachea, obstruction to the airway usually occurs due to venous congestion, which causes laryngeal oedema and tracheal obstruction.

A neck haematoma need not be very large to cause this.

Pressure applied to frank bleeding from the neck can compromise a patient’s airway.

Immediate intern management

Attend patient and make rapid assessment.

If patient unconscious/severe respiratory distress/STRIDOR/respiratory arrest

  1. Tell nursing staff to call Code Blue then move to head end of bed.
  2. Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
  3. Clear mouth – suction secretions.

If the airway is compromised then the priority is the establishment of a patent airway by either intubation or creation of a surgical airway. Control of haemorrhage is a secondary priority once an airway is established.

As a matter of urgency, in the ward, remove any skin staples and cut the sutures from the wound down to and including the deeper fascial sutures.

Scoop out any blood clot.

This should release the pressure against the trachea and relieve the upper respiratory tract obstruction.

If still obstructed and trachea on view, attempt to incise and insert endotrachael tube.

Neck haemorrhage without airway obstruction

  1. Call Code Blue.
  2. Assess airway.
  3. Assess breathing.

If stable put direct pressure over the bleeding point.

This may compromise the patient’s airway.

  1. Give oxygen by mask and sit patient up.
  2. Transfer to theatre for control of haemorrhage and resuture of wound. Escort the patient to the theatre urgently.

Clinical features (obtain rapidly)

History

Examination

Causes

Investigations

  1. ABG
  2. CXR = less useful
  3. Basic blood tests

An ECG can be done at a later time.

Notes

The patient will not need analgesia when a fresh surgical wound is opened on the ward.

This is a lifesaving manoeuvre and should be performed by the first doctor at the scene of a patient with signs of upper respiratory tract obstruction post neck surgery.

Removal of sutures is done in the ward. There is insufficient time to transfer patient to theatre. See over the page for illustrations.

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After thyroid surgery, sutures need to be removed.

  1. Skin
  2. Platysma
  3. Strap muscles

L Hemithyroidectomy showing sutures in strap muscles

After carotid surgery, sutures need to be removed.

  1. Skin
  2. Platysm

Skin may be closed by metal clips, skin sutures, or a subcuticular suture.

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This photo shows a subcuticular skin closure of a left neck carotid endarterectomy incision. This stitch needs to be removed or cut the length of the incision. Note the ear lobe to the right and the drain tube to the left. The sternal notch is beneath the drapes in the top left corner. Drain tubes cannot be relied upon to prevent a neck haematoma developing.

Carotid skin closure

After removal of the skin sutures an underlying haematoma may still not be visible.

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After removal of skin sutures, the platysma sutures must be removed. This photo shows the platysma sutures partly removed in the upper part of the wound (the right side of the photo).

The haematoma is visible in the upper part of the wound where the platysma layer has been opened.

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Opening the platysma

The wound is now completely open and the haematoma evacuated. Note the drain tube is now completely visible (a haematoma can develop even though a drain tube is in place).

Definitive management

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