Abstract SNACC-71

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SHOUT AIRWAY RISK TOOL-recognising neck haematoma after anterior neck surgery

Kyle B, Wilson S
National Hospital for Neurology and Neurosurgery, London, , United kingdom

Introduction
Anterior neck haematoma is rare but well recognised following anterior neck surgery. It is a time-critical event due the potential for catastrophic airway compromise. Clinical presentation may initially go undetected and delay management even in a specialist centre.

Background
We describe the SHOUT airway risk tool initiated by the anaesthetic department of a tertiary neurosciences centre after delayed recognition and late senior clinician review resulted in near-fatal outcome. We perform in excess of sixty anterior cervical decompressions annually, with the last haematoma occurring five years previously. Reported incidence varies between 0.2%-1.9% (1). We aimed to establish a method for early bedside detection.

Method
We performed a literature search to identify frequently presenting features of anterior neck haematoma. Oesophageal symptoms (dysphagia, drooling) and respiratory symptoms (tachypnoea, dyspnoea, hypoxia and stridor) together with anterior neck swelling were most frequently cited. “SHOUT” = Swelling or stridor, Hoarseness or voice change, Oesophageal dysphagia or drooling, Unexpected behavior or agitation, and Tachypnoea enables key features to be recalled. We added “AIRWAY RISK TOOL” to emphasise the purpose of SHOUT, as well as the airway risk posed by anterior neck surgery. The SHOUT tool is applied by the anaesthetist to the patient observations chart intra operatively in all patients undergoing anterior neck surgery, and is designed to be clearly visible to anyone recording or reviewing observations post surgically. Nursing staff assess for features of SHOUT alongside routine observations for the first 24 hours and alert a senior neurosurgeon immediately if a SHOUT feature develops. Using SHOUT has enabled important changes. First, patients are assessed regularly for relevant clinical features. Second, rapid senior escalation is facilitated.The question of if the anaesthetist should be routinely contacted was challenging. We agreed immediate neurosurgical assessment (and anaesthetic referral if necessary) was paramount in the first instance. SHOUT was introduced via email, advertisement and bedside education.

Conclusion
We devised the SHOUT tool, a simple extension of routine bedside observations post anterior neck surgery. We experienced a rare complication of anterior neck haematoma with near-fatal outcome. This is a life-threatening and time-critical event. Its initial presentation and rare occurrence mean a less experienced clinician may miss it. The routine use of SHOUT after anterior neck surgery may facilitate early recognition of haematoma by junior nursing or medical staff, prompting senior review. Since neck haematoma is rare however assessing of the impact of SHOUT may take several years.

References
(1) Palumbo A, Caiati J et al. Airway Compromise Due to Wound Haematoma Following Anterior Cervical Spine Surgery. Open Orthop J. 2012; 6: 108–113.

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