Management of Pulsatile Hematoma Post Total Thyroidectomy
A pulsatile hematoma after total thyroidectomy represents an airway emergency requiring immediate bedside wound opening using the SCOOP approach, regardless of whether senior surgical or anesthetic personnel have arrived. 1, 2
Immediate Recognition and Initial Actions
The pulsatile nature of the hematoma indicates active arterial bleeding with ongoing expansion, making this a true surgical emergency that demands action within minutes, not hours. 1
Key immediate steps:
- Immediately call for help - notify both senior anesthetist and senior surgeon simultaneously, but do not delay intervention waiting for their arrival 1, 2
- Administer supplemental oxygen immediately via non-rebreather mask 2, 3
- Position patient head-up (reverse Trendelenburg or sitting) to optimize airway patency and reduce venous congestion 2, 4
- Prepare for immediate bedside wound opening - do not transport patient to operating room if any signs of airway compromise are present 1, 2
The SCOOP Approach for Emergency Hematoma Evacuation
If any signs of airway compromise exist (stridor, tachypnea, anxiety, difficulty breathing, oxygen desaturation), immediately proceed with bedside wound opening using SCOOP: 1, 2, 4
- Skin exposure - remove dressing completely
- Cut sutures - cut all skin sutures or staples
- Open skin - open the entire skin incision
- Open muscles - open both superficial (strap muscles) and deep muscle layers
- Pack wound - pack the wound to achieve hemostasis
Critical pitfall: Stridor is a late sign of airway compromise - intervention must occur well before stridor develops. 3, 4 The presence of a pulsatile hematoma itself warrants immediate action given the high risk of rapid deterioration. 1
Equipment and Personnel Requirements
A post-thyroid surgery emergency box must be immediately available at bedside containing: 1, 2, 3
- Scalpel for wound opening
- Suture removal kit
- Wound packing materials
- Tracheal tube and bougie for emergency front-of-neck airway access
Personnel considerations:
- An experienced senior clinician should perform intubation if required, as significant laryngeal and pharyngeal edema will be present 5, 6
- Never lay the patient flat during intubation preparation, as this may precipitate acute airway obstruction 5
- Have emergency front-of-neck airway equipment immediately available, as conventional intubation may be impossible 1, 3
Post-Evacuation Management
After bedside hematoma evacuation:
- Transport to operating room for formal exploration, identification of bleeding source, and definitive hemostasis 5, 7
- The bleeding source in pulsatile hematomas is typically arterial vessels in the main operative field 8
- Consider elective ventilation with PEEP if significant supraglottic edema or pulmonary edema has developed 6
- Intravenous dexamethasone may reduce upper airway edema 4
Why Pulsatile Hematomas Are Particularly Dangerous
Pulsatile hematomas indicate active arterial bleeding with rapid expansion potential. 8 Unlike venous oozing, arterial bleeding can cause:
- Rapid airway compression within minutes 1, 6
- Severe supraglottic edema from venous and lymphatic obstruction 6
- Negative pressure pulmonary edema from attempted inspiration against closed airway 6
- Cardiac arrest from complete airway obstruction 6
Most hematomas requiring reexploration (72.7%) occur within the first 6 hours postoperatively, but the pulsatile nature indicates this is an active, evolving emergency regardless of timing. 9, 3
Common Pitfalls to Avoid
- Do not wait for imaging - clinical diagnosis is sufficient and imaging delays definitive management 1
- Do not rely on drains - drains do not prevent hematoma formation, and clot formation may prevent drainage while hematoma continues to expand 3, 4
- Do not transport to operating room if any airway compromise exists - evacuate at bedside first 1, 2
- Do not attempt conservative management of a pulsatile hematoma - the arterial nature demands surgical intervention 5, 7