A 67-year-old woman is evaluated in the intensive care unit for neck swelling. An hour ago, the patient was admitted to the ICU for treatment of pyelonephritis complicated by septic shock and disseminated intravascular coagulation. A central line catheter was placed in the right internal jugular vein. The insertion was difficult, requiring multiple attempts. X-ray after placement revealed the catheter to be in a good position. Over the past 30 minutes, she has developed swelling at the site of the catheter and a feeling of tightness in her neck. She also feels her voice is changing. On examination, there is ballotable swelling under the site of the catheter with surrounding ecchymosis, and the trachea is deviating to the left. The voice sounds hoarse. Which of the following is the most appropriate next step in management of this patient?

Question

A 67-year-old woman is evaluated in the intensive care unit for neck swelling.  An hour ago, the patient was admitted to the ICU for treatment of pyelonephritis complicated by septic shock and disseminated intravascular coagulation.  A central line catheter was placed in the right internal jugular vein.  The insertion was difficult, requiring multiple attempts.  X-ray after placement revealed the catheter to be in a good position.  Over the past 30 minutes, she has developed swelling at the site of the catheter and a feeling of tightness in her neck.  She also feels her voice is changing.  On examination, there is ballotable swelling under the site of the catheter with surrounding ecchymosis, and the trachea is deviating to the left.  The voice sounds hoarse.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This coagulopathic patient with an enlarging fluid collection after difficult intravenous cannulation has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction from: Direct mechanical airway compression collapsing the structural support of the airway and causing narrowing of the lumen Compression of the lymphovasculature, leading to impaired venous drainage, which causes vascular congestion and intrinsic laryngeal mucosal edema that narrows the airway lumen Signs of airway obstruction can include tracheal deviation and hoarseness (as seen in this patient); other clinical features include stridor, dysphagia, voice changes, and tripod positioning. However, patients can initially have few or no symptoms, including a normal peripheral blood oxygenation concentration, until rapid (secure the airway, typically via oral endotracheal intubation. Ideally, a surgical airway should be avoided due to the increased risk of bleeding, but it may become unavoidable if the larynx cannot be visualized for intubation. (Choices A and F) Treatment of acute disseminated intravascular coagulation (DIC) requires correction of the underlying disorder and supportive measures. For severe deficiencies, blood products (eg, cryoprecipitate, platelets) may be needed. However, tranexamic acid (an antifibrinolytic agent) is contraindicated in acute DIC due to the increased risk of thrombotic events. Regardless, protecting the patient's airway is the immediate concern. (Choice B) Compression via direct pressure or with a compressive dressing is often used to control bleeding at many sites. However, when bleeding is in the neck, compression can worsen the airway obstruction. (Choice C) A CT scan of the neck may show the hematoma and may characterize swelling and/or displacement of the airway and may be indicated after the airway is secured. However, it is not needed to diagnose an expanding neck hematoma and obtaining one would delay possibly life-saving treatment. (Choice E) Removing the catheter may worsen the hematoma because the catheter may be tamponading some of the blood flow. In addition, removal would not protect the airway, and its presence still may be needed to deliver resuscitative fluids and treatment medications. Educational objective: An expanding neck hematoma can be life-threatening due to upper airway obstruction. The first step in management is to secure the airway, usually with an endotracheal tube. References: Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis. (http://www.ncbi.nlm.nih.gov/pubmed/24856739)

A 67-Year-Old Woman Is Evaluated in the Intensive Care Unit