Management of Retropharyngeal Hematoma

Immediate Initial Actions

Administer high-flow supplemental oxygen immediately upon suspicion of retropharyngeal hematoma, and position the patient in a head-up position to optimize airway patency and reduce airway edema, as recommended by the American Society of Anesthesiologists 1, 2
Ensure portable lighting is available for adequate visualization, according to the American Society of Anesthesiologists 1
Assess for airway compromise using the DESATS criteria, which includes difficulty swallowing, increase in early warning score, anxiety or agitation, tachypnea, and stridor, as recommended by the American College of Surgeons 1, 2, 3, 4

If signs of airway compromise are present, immediately call for help and notify a senior anesthetist, and proceed directly to bedside hematoma evacuation using the SCOOP approach, as recommended by the American Society of Anesthesiologists 1, 2, 5
If no immediate airway compromise but concerns are raised, arrange immediate senior surgical review and perform flexible endoscopic laryngeal assessment to evaluate hematoma extent and airway patency, according to the American Academy of Otolaryngology 1, 2

If hematoma evacuation does not resolve airway compromise, proceed to emergency tracheal intubation, and use videolaryngoscopy at first attempt, as recommended by the American Society of Anesthesiologists 1, 5
If cannot intubate, cannot oxygenate, proceed immediately to scalpel cricothyroidotomy or emergency tracheostomy, as recommended by the American College of Surgeons 5

Stridor is a late sign of airway compromise, and intervention should not be delayed until stridor develops, according to the American Society of Anesthesiologists 1, 2
Multiple intubation attempts worsen outcomes, and early progression to front-of-neck airway should be considered rather than repeated attempts, as recommended by the American Society of Anesthesiologists 1, 5

Transfer the patient to level 2 or 3 care for close postoperative observation following emergency evacuation, as recommended by the American College of Surgeons 5
Maintain head-up positioning and avoid unnecessary positive fluid balances to reduce airway edema, according to the American Society of Anesthesiologists 4
Monitor for signs of mediastinitis, including severe sore throat, deep cervical pain, chest pain, dysphagia, and fever, as recommended by the American Academy of Otolaryngology 4