What is the initial recommended goal of care for a post-thyroidectomy patient with mild restlessness and stable airway, breathing, and circulation?

Initial Goal of Care: Assess and Manage Hypocalcemia

The initial recommended goal of care is to immediately assess for and manage hypocalcemia by checking serum calcium levels and monitoring for signs of hypoparathyroidism, as this is the most common early complication presenting with drowsiness and restlessness in the first postoperative day after thyroidectomy. 1, 2

Immediate Assessment Priority

The clinical presentation of drowsiness with mild restlessness on postoperative day one strongly suggests hypocalcemia from hypoparathyroidism, which occurs in 20-30% of patients after total thyroidectomy and represents the most frequent early complication. 3 This is far more common than other complications like hematoma (0.45-4.2%) or recurrent laryngeal nerve injury (3-5%). 1, 3

Key Clinical Features to Assess

• Perioral numbness and peripheral tingling are pathognomonic for hypocalcemia 2
• Muscle cramps and carpopedal spasm indicate progression 1, 2
• Restlessness and altered mental status can be early manifestations 1
• Check for Chvostek's and Trousseau's signs 1

Immediate Management Steps

1. Laboratory Confirmation

• Check serum calcium levels immediately to confirm hypocalcemia 1, 2
• Monitor calcium levels every 6-8 hours until stable 1, 2
• Continue monitoring during the first 24-48 hours after surgery 1

2. Treatment Initiation

• Administer calcium plus vitamin D supplementation for at least 10 days if hypocalcemia is confirmed 3
• The prognosis is generally good, with most cases being temporary (only 1.1-2.6% become permanent) 1, 2

Critical Differential: Rule Out Airway Compromise

While hypocalcemia is most likely, you must simultaneously assess for hematoma causing airway compromise, though this typically presents earlier (within 6 hours) and with more dramatic symptoms. 4

Signs of Hematoma (Less Likely but Life-Threatening)

• Visible neck swelling 4
• Respiratory distress or stridor 4
• Difficulty breathing or noisy breathing 4
• If suspected, implement SCOOP protocol: Skin exposure, Cut sutures, Open skin, Open muscles, Pack wound 1

Why Not Recurrent Laryngeal Nerve Injury?

Recurrent laryngeal nerve injury presents with voice changes, hoarseness, and dysphonia—not drowsiness or restlessness. 4, 2 The patient's ability to nod suggests the airway is stable and vocal cord function is not the primary concern. 4

Common Pitfall to Avoid

Do not attribute drowsiness and restlessness to residual anesthesia or pain medication alone without first ruling out hypocalcemia, as untreated severe hypocalcemia can progress to seizures, laryngospasm, and cardiac arrhythmias. 1, 2 The temporal relationship (first postoperative day) and symptom pattern (drowsiness with restlessness) are classic for evolving hypocalcemia. 1, 3