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A 69-year-old man has been in the post-anesthetic recovery unit (PACU) for 6 hours with a slowly expanding neck hematoma following an uneventful left carotid endarterectomy under general anesthesia. Over the last 45 minutes he has become symptomatically short of breath. Neurosurgery has booked him to return to the operating room (OR) for wound exploration and evacuation of hematoma. Preoperatively, he was otherwise healthy, taking no medications, and was noted to have normal-looking airway anatomy. Post-induction at the original surgery, he was documented to have been easy to ventilate using a bag-mask, presented a Cormack/Lehane (C/L)1 Grade 1 view at direct laryngoscopy using a Macintosh #3 blade, and the trachea was easily intubated with an 8.5-mm internal diameter (ID) endotracheal tube (ETT).

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In the PACU he is sitting upright, breathing oxygen at 10 L·min−1 via a non-rebreathing facemask. Although restless, he is rational, complaining of dyspnea, dysphagia, and neck pain. Blood pressure is 180/95 mm Hg, heart rate 100 beats per minute (bpm), respiratory rate 30 breaths per minute, and his SpO2 is 95%. He is audibly stridulous. Under a blood-stained dressing, the left side of his neck looks visibly enlarged and discolored (Figure 55-1). The patient is 5 ft 10 in (178 cm) in height and weighs 230 lb (105 kg). He has vascular access. An OR is being prepared for his return.

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Figure 55-1.
Graphic Jump Location

The patient. A dressing is covering the site of the surgical incision.

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55.2.1 In What Ways Might This Patient Present Difficulty with Airway Management? What Are Key Aspects of the Airway Examination in This Situation?

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This is an urgent situation. The patient must be quickly assessed and decisions made. Although some patients with neck hematomas are simply observed, case reports attest to difficulty in predicting if or when these individuals will go on to sudden and catastrophic airway obstruction.2-4 As part of the patient's evaluation, a formal airway examination should be performed, seeking predictors of difficulty in all aspects of airway management.5 Even though the patient's anatomy presented no difficulty with airway management earlier that day, the presence of a neck hematoma changes everything. With evidence of obstructing pathology in the airway—as manifested by stridor, neck swelling, and the patient's dyspnea and agitation—difficulty can now be anticipated with both bag-mask-ventilation (BMV) and use of an extraglottic device (EGD). Similarly, direct laryngoscopy in the presence of pathological obstruction may also be difficult as anatomic landmarks become distorted, displaced, or obscured. Finally, cricothyrotomy by percutaneous or open surgical routes may also be difficult as landmarks are shifted or become indistinct.

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If time and patient cooperation permit, any patient with obstructing airway pathology can be considered for further assessment by nasopharyngoscopy. This is generally well tolerated and can give information about any displacement of the larynx to left ...

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