Collaborative approach to the emergency management of post-thyroidectomy haematoma

Abstract

Background: The risk of haemorrhage after thyroid surgery is 1–5%. Our local incidence at Royal Surrey Hospital over the past 2 yr is 2%. As haematoma develops, pressure in the neck increases leading to impaired venous return from the head, causing progressive laryngeal oedema. Opening the neck wound allows immediate release of pressure, which should prevent worsening of the oedema and help optimise intubation conditions. Difficult Airway Society (DAS), British Association of Endocrine and Thyroid Surgeons (BAETS), and Ear, Nose and Throat UK (ENT UK) developed consensus guidelines for early recognition and management of haematoma after thyroid surgery, along with a series of recommendations that would ‘improve patient safety by identifying key areas in clinical management, training and institutional preparedness’.1 Methods: Initially we wanted to assess our local policies and awareness of the guidelines, and any specific issues related to post-thyroidectomy haematoma management in our hospital. We surveyed the multidisciplinary team (MDT) including PACU nurses, anaesthetists, and ENT (ear, nose, throat) surgeons, to assess their knowledge of the clinical signs of impending airway compromise secondary to haematoma development and the key steps in its management. We also reviewed the postoperative areas for the presence of appropriate equipment to manage a post thyroidectomy haematoma. Results: Our hospital does not currently have a specific ‘post-thyroidectomy haematoma management’ box in any of the postoperative areas or wards, nor does any equipment accompany the patient out of theatre for this eventuality. Most members of the MDT involved with these patients had not received any formal training in post-thyroidectomy haematoma recognition or management and were not aware of any guidelines covering this scenario. The PACU nurses knew the most important symptoms of impending airway compromise, but not all were aware of the more subtle signs (e.g. anxiety). More ENT surgeons (85%) were aware of the guidelines than anaesthetists (33%). Of the anaesthetists, 75% were aware that part of the management includes releasing the sutures/clips; however, only 25% knew where to find the appropriate equipment to carry this out. All ENT surgeons were aware of the appropriate management; however, they highlighted the importance of formal teaching given that often only the skin was opened and not the deeper tissues, which would not necessarily treat the problem. Conclusions: Going forward, we plan to introduce printed guidelines (DESATS [Difficulty swallowing; Early warning score; Swelling; Anxiety; Tachypnoea; Stridor] for monitoring plus management of suspected haematoma) to accompany the patient from theatre to PACU and the ward. We will also bring in an emergency box with the SCOOP (skin exposure, cut sutures, open skin, open muscles, pack wound) guideline included in the postoperative areas. Finally, we are arranging appropriate MDT education/training sessions on the guidelines and the role of the emergency box. We aim to then re-survey the MDT to ascertain their confidence managing these cases, and to identify any problems with the use of the guidelines or the box. 1.Iliff HA, El-Bogdadhly K, Ahmad I, et al. Anaesthesia 2022: 77; 82–95