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:
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 (<min) decompensation.
Although some expanding neck hematomas (eg, post-surgical) should be evacuated immediately, in this patient with a severe coagulopathy and possible damage to great vessels, it is more appropriate to adequately 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.
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.
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.
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.