What is the best course of action for a likely adult patient who underwent elective neck liposuction 3 days ago and now presents with massive bruising and swelling of the neck?

Immediate Management of Post-Liposuction Neck Hematoma

You must immediately evacuate the hematoma at bedside if there are any signs of airway compromise (difficulty breathing, stridor, tachypnea, oxygen desaturation), as this is a life-threatening emergency requiring urgent decompression before attempting transfer to the operating room. 1

Immediate Assessment and Stabilization

Evaluate for Airway Compromise

• Assess for critical signs: stridor, difficulty breathing, tachypnea, oxygen desaturation, or rapidly expanding neck swelling 1
• Position the patient head-up and administer high-flow supplemental oxygen immediately 1, 2
• Call for immediate help including anesthesia and activate your facility's peri-arrest protocol if airway compromise is present 1
• Note that stridor is often a late sign and may warrant immediate intervention rather than observation 1

If Airway Compromise is Present: Bedside Evacuation

Use the SCOOP approach immediately at bedside (no local anesthetic needed): 1

• Skin exposure: expose the surgical site
• Cut sutures: remove all skin sutures/staples
• Open skin: open the incision completely
• Open muscles: open both superficial AND deep muscle layers (critical step)
• Pack wound: pack the wound to achieve hemostasis

This must be done before attempting transfer to the operating room, as airway collapse can occur during transport 1

If No Immediate Airway Compromise

Obtain Urgent Surgical Consultation

• Arrange immediate on-site senior surgical review (attending or senior resident level) 1
• If senior surgical review is unavailable, immediately contact senior anesthesia 1
• Consider flexible laryngoscopy by an experienced operator to assess airway patency 1

Medical Interventions

• Administer tranexamic acid 1g IV over 10 minutes, followed by 1g over 8 hours (must be given within 3 hours of bleeding onset for mortality benefit) 3, 2
• Consider IV dexamethasone to reduce upper airway edema, though effect is not immediate 1
• Increase monitoring frequency with serial neurological and airway assessments 1

Diagnostic Imaging

• CT angiography (CTA) should be performed in hemodynamically stable patients without airway compromise to identify active bleeding source 3
• This guides whether angiographic embolization is needed for ongoing arterial hemorrhage 3

Definitive Management

For Active Arterial Bleeding

• Selective angiographic embolization is recommended for identified arterial bleeding on CTA or ongoing hemodynamic instability 3
• Use microcoils as primary embolic agent in a superselective, distal-to-proximal fashion 3

For Venous Oozing or Diffuse Bleeding

• Surgical exploration in the operating room with evacuation, identification of bleeding source, and wound packing 3, 2
• Multiple drains should be placed to prevent reaccumulation 4, 5

Coagulopathy Management

• Maintain fibrinogen >1 g/L and platelet count >75 × 10⁹/L 3, 2
• Administer fresh frozen plasma (15 ml/kg) if PT/aPTT >1.5 times normal 3
• Use fibrinogen concentrate or cryoprecipitate for rapid fibrinogen replacement if coagulopathic 3

Post-Intervention Care

• Admit to critical care for monitoring of coagulation parameters, hemoglobin, and vital signs 3, 2
• Start venous thromboprophylaxis as soon as hemostasis is secured, as patients develop prothrombotic state after hemorrhage 3, 2
• Communicate with the patient about the complication, including offering referral for psychological support 1

Critical Pitfalls to Avoid

• Do not delay bedside evacuation if airway compromise is present—attempting to transfer to OR first can result in complete airway obstruction and death 1
• Do not assume opening only the skin is sufficient—you must open both superficial and deep muscle layers to prevent ongoing compression 1
• Do not wait for imaging if there are signs of airway compromise—clinical assessment supersedes radiographic confirmation 1
• Do not administer tranexamic acid after 3 hours from bleeding onset, as mortality benefit is lost 3, 2

Note: While hematoma after neck liposuction is rare (occurring in <1% of cases), it requires immediate recognition and aggressive management due to the confined anatomical space and risk of airway compromise 4, 5, 6