What is the management of a retropharyngeal hematoma?

Management of Retropharyngeal Hematoma

Immediately administer supplemental oxygen, position the patient head-up, and assess for airway compromise using the DESATS criteria—if any signs of airway obstruction are present, evacuate the hematoma at bedside using the SCOOP approach before attempting intubation. 1, 2

Immediate Initial Actions

Oxygenate and position the patient:

• Administer high-flow supplemental oxygen immediately upon suspicion of retropharyngeal hematoma 1, 2
• Position patient in head-up (upright) position to optimize airway patency and reduce airway edema 1, 2
• Ensure portable lighting is available for adequate visualization 1

Assess for airway compromise using DESATS criteria: 1, 2

• Difficulty swallowing/discomfort
• Increase in Early warning score
• Swelling (neck swelling, expanding hematoma)
• Anxiety or agitation
• Tachypnea/difficulty breathing
• Stridor (note: this is a late sign and warrants immediate intervention) 1, 2

Decision Algorithm Based on Airway Status

If Signs of Airway Compromise Present:

Immediately call for help via local peri-arrest protocols and notify senior anesthetist 1, 2

Proceed directly to bedside hematoma evacuation using SCOOP approach: 1, 2

• Skin exposure
• Cut sutures (subcuticular sutures)
• Open skin to expose strap muscles
• Open muscles (strap muscles) to expose trachea
• Pack wound with gauze

Critical technical points:

• Local anesthetic infiltration is NOT required in emergency situations 1
• Open both superficial AND deep layers (strap muscles) to prevent ongoing hematoma formation 1
• This should be performed at bedside regardless of location 1

If No Immediate Airway Compromise but Concerns Raised:

Arrange immediate senior surgical review (ENT specialist or consultant); if unavailable, arrange senior anesthetic review 1, 2

Perform flexible endoscopic laryngeal assessment by experienced operator to evaluate hematoma extent and airway patency 1, 2

Administer adjunctive medical therapy: 1, 2

• Intravenous dexamethasone to reduce upper airway edema (effect not immediate)
• Intravenous tranexamic acid to reduce bleeding (effect not immediate)

Increase observation frequency and consider transfer to operating theater, PACU, or ICU for close monitoring 1, 2

Airway Management if Evacuation Fails

If hematoma evacuation does not resolve airway compromise, proceed to emergency tracheal intubation: 1

Intubation should be attempted AFTER opening the wound and evacuating the hematoma to optimize conditions and prevent worsening laryngeal edema 1

Technical approach:

• Use videolaryngoscopy at first attempt 1
• Use smaller tracheal tube (6.0 mm internal diameter) and/or bougie as adjuncts 1, 2
• Confirm successful intubation with capnography 1
• Limit number of intubation attempts as multiple attempts exacerbate laryngeal edema 1

If cannot intubate, cannot oxygenate:

• Proceed immediately to scalpel cricothyroidotomy or emergency tracheostomy 1
• These are preferred over cannula cricothyroidotomy as they reduce gas trapping, maximize respiratory gas exchange, and allow egress of gas with complete upper airway obstruction 1
• The scalpel can be used to both open the existing neck wound and make incisions in the cricothyroid membrane or trachea 1
• Ongoing bleeding is NOT a contraindication to emergency front-of-neck airway 1

Conservative Management Considerations

Conservative management may be appropriate for: 3, 4

• Small, nonexpanding hematomas that do not seriously compromise the airway
• Patients with visible glottis on laryngoscopy and minimal dyspnea
• Hematomas extending below the tracheal bifurcation (pressure distribution may ease upper airway obstruction) 4

Conservative management requires: 3, 4

• Close observation with frequent vital sign monitoring
• Ability to rapidly secure airway if deterioration occurs
• Patient emotional stability and cooperation 4

Critical Pitfalls to Avoid

Stridor is a late sign of airway compromise—do not wait for stridor to develop before intervening 1, 2

Drains do not prevent hematoma formation and clot formation may prevent free drainage, providing false reassurance 1

Multiple intubation attempts worsen outcomes—consider early progression to front-of-neck airway rather than repeated attempts 1

Anticoagulation-related hematomas require rapid reversal with fresh frozen plasma and vitamin K if coagulopathy is present 5

Post-Evacuation Care

Transfer to level 2 or 3 care for close postoperative observation following emergency evacuation 1

Maintain head-up positioning and avoid unnecessary positive fluid balances to reduce airway edema 6

Monitor for signs of mediastinitis: severe sore throat, deep cervical pain, chest pain, dysphagia, and fever 6

Offer psychological support and clinical psychology referral given the distressing nature of this event 1