Today’s question targets rapid airway prioritization after neck surgery. Postoperative thyroid patients can deteriorate fast if swelling or bleeding narrows the airway. Knowing what to do first protects the patient while the team prepares definitive care. This thinking translates directly to real shifts on surgical floors and PACU.
Clinical Scenario
A 46-year-old woman is 2 hours post–total thyroidectomy for a large multinodular goiter. She is on the surgical unit. History: hypertension controlled with amlodipine, no known allergies. Current assessment: anxious, voice hoarse, difficulty swallowing saliva with intermittent drooling, and noisy inspiratory stridor. Vital signs: BP 148/88, HR 118, RR 26, SpO2 90% on 2 L nasal cannula. The anterior neck dressing shows a small area of fresh sanguineous drainage. The nurse notes subtle, firm swelling above and below the incision line.
The Question
Which action should the nurse take first?
Answer Choices
- Check for Chvostek and Trousseau signs to assess for hypocalcemia.
- Increase oxygen to 6 L via nasal cannula and reassess in 15 minutes.
- Loosen the neck dressing and position the patient supine to reduce strain.
- Activate the rapid response team, apply high-flow oxygen via nonrebreather, and prepare emergency airway equipment (tracheostomy set and suction).
Correct Answer
D. Activate the rapid response team, apply high-flow oxygen via nonrebreather, and prepare emergency airway equipment (tracheostomy set and suction).
Detailed Rationale
This is a Med-Surg airway emergency. The combination of new stridor, difficulty swallowing, tachypnea, anxiety, and falling SpO2 after thyroid surgery points to impending airway obstruction from laryngeal edema or a developing neck hematoma. With airway compromise, the safest sequence follows ABCs:
- Airway first: Stridor is a high-grade warning that the upper airway is narrowing. Immediate escalation is required. Activate the rapid response team to bring more hands and advanced airway support quickly.
- Provide high FiO2 now: Switch from nasal cannula to a nonrebreather mask to deliver a higher, more reliable fraction of inspired oxygen while you work to stabilize the patient. Nasal cannula cannot meet oxygenation needs during acute upper airway compromise.
- Prepare to secure the airway: Thyroid and anterior neck swelling can make endotracheal intubation difficult. A tracheostomy set and suction must be at the bedside. Have bag-valve-mask (BVM) available. Suction clears blood or secretions that worsen obstruction.
- Positioning: Keep the head of bed elevated and the neck neutral to reduce airway collapse and swelling. Avoid supine positioning.
- Notify the surgeon concurrently: While the rapid response is activated, alert the surgeon since a neck hematoma may need urgent decompression in the room or OR.
- Monitor closely: Continuous pulse oximetry and frequent vital signs. Reassess breath sounds, voice changes, and neck swelling. Have IV access confirmed for potential medications and transport.
Concerns like hypocalcemia (from parathyroid injury) matter, but only after the airway is secured. Hypocalcemia often shows perioral tingling, paresthesias, and muscle spasms; it can also cause laryngospasm. If suspected later, anticipate labs and IV calcium gluconate per order. In the first minutes, however, the priority is preventing complete obstruction.
Why the Other Options Are Wrong
- A. Check for Chvostek and Trousseau signs: These assess hypocalcemia but do not treat the immediate threat. Provoking a spasm with a BP cuff (Trousseau) can also distress the patient. With stridor and hypoxia, delaying airway interventions is unsafe.
- B. Increase oxygen to 6 L nasal cannula and reassess: Nasal cannula at 6 L still delivers variable, limited FiO2 and does not address a rapidly narrowing upper airway. “Reassess in 15 minutes” dangerously delays escalation.
- C. Loosen the neck dressing and position supine: Loosening a fresh surgical dressing without an order or team present can release tamponade on a hematoma and worsen bleeding. Supine positioning increases airway collapse and aspiration risk. Neither action treats the core problem.
Key Takeaways
- After thyroid surgery, new stridor, hoarseness, dysphagia, and dropping SpO2 signal impending airway obstruction.
- Follow ABCs: call for help early, deliver high-flow oxygen, and prepare for a difficult airway (trach set and suction).
- Avoid delays for diagnostic maneuvers when airway compromise is present.
- Supine positioning and dressing manipulation can worsen the situation.
- On-shift mini-checklist for post-thyroidectomy:
- HOB 30–45 degrees; neck neutral.
- Tracheostomy set, suction, and BVM at bedside.
- Humidified oxygen as ordered; continuous pulse oximetry.
- Assess voice, swallowing, stridor, and neck swelling every 1–2 hours initially.
- Check front and back of neck/shoulders for dependent bleeding.
- Know where IV calcium gluconate is stored; monitor for hypocalcemia signs.
Quick Practice Extension
- What early assessments could help you detect a developing neck hematoma before stridor appears?
- If the patient were also reporting perioral tingling and hand cramps, what labs and medications would you anticipate after the airway is stabilized?
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com