What is the most appropriate immediate management for a patient with severe respiratory distress and a swollen neck 3 hours after a subtotal thyroidectomy?

Management of Post-Thyroidectomy Neck Hematoma with Respiratory Distress

The most appropriate immediate management for a patient with severe respiratory distress and swollen neck after thyroidectomy is to open the wound at the bedside using the SCOOP approach (skin exposure, cut sutures, open skin, open muscles, pack wound). 1

Initial Assessment and Immediate Actions

When faced with a patient showing signs of respiratory distress and neck swelling 3 hours after thyroidectomy:

• Immediately call for senior help while proceeding with management 1
• Administer supplemental oxygen and position the patient in a head-up position to optimize airway patency 1, 2
• Recognize that the clinical presentation strongly suggests post-thyroidectomy hematoma with airway compromise, requiring immediate intervention 1

Immediate Wound Management (SCOOP Approach)

For a patient with severe respiratory distress and swollen neck, immediate bedside evacuation of the hematoma is required:

• Skin exposure: Expose the surgical site completely 1
• Cut sutures: Cut all subcuticular sutures 1
• Open skin: Open the skin incision to expose strap muscles 1
• Open muscles: Open the strap muscles to expose the trachea 1
• Pack wound: Cover the wound with a sterile pack 1

This systematic approach prevents ongoing hematoma formation and relieves tracheal compression 1.

Important Clinical Considerations

• Local anesthetic infiltration is not required when opening the wound in this emergency situation 1
• Stridor may be a late sign of airway compromise and should not be waited for before intervening 1, 2
• Drains do not prevent hematoma formation and may provide false reassurance if clots block drainage 1, 2

Post-Evacuation Management

If hematoma evacuation fails to stabilize the patient:

• Emergency tracheal intubation should be considered, ideally after opening the wound and evacuating the hematoma 1
• Intubation should be performed by experienced personnel, with consideration of videolaryngoscopy and using a smaller endotracheal tube 1
• Multiple intubation attempts should be avoided as they may exacerbate laryngeal edema 1
• Early progression to front-of-neck airway should be considered if intubation is unsuccessful 1

Common Pitfalls to Avoid

• Delaying intervention while waiting for operating room availability can be fatal 1, 2
• Administering morphine would worsen respiratory depression and mask symptoms 1, 2
• Attempting urgent intubation without first relieving the compression can be extremely difficult and potentially worsen the situation 1
• Removing only skin sutures without opening the deep fascia will not adequately relieve tracheal compression 1