Stridor after anterior cervical fusion58-year-old woman, 68 kg, day 0 after a 6-hour C3–C6 anterior cervical discectomy and fusion

The patient

The examiner asks

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1. Consider

   You are called to see her. What are you thinking?

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   • A 58-year-old with new stridor 3 hours after a long three-level anterior cervical fusion. Patient
   • Two main causes: a wound haematoma pressing on her airway, or swelling of pharynx and larynx. Disease
   • Six hours of retraction makes swelling likely; a tense, enlarging neck points to haematoma. Surgery
   • Retraction can also injure a recurrent laryngeal nerve and paralyse a vocal cord.
   • SpO2 92% with RR 28 means she is tiring; this is an airway emergency. Airway

2. Plan

   What is your immediate plan?

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   • Sit her up 45–90 degrees, 100% oxygen by mask, and call my senior and the surgeon now. (Airway)
   • Collar off and look at the wound: if it's tense, the surgeon opens it at the bedside.
   • For swelling: nebulised racemic adrenaline 0.5–0.75 mL of 2.25% in 2.5 mL saline.
   • Dexamethasone 4–8 mg IV, repeated every 8–12 hours.
   • If she worsens, theatre for awake fibreoptic intubation, sitting, with front-of-neck kit open.
   • No paralysis and minimal sedation; her own muscle tone may be all that keeps the airway open.

3. Crisis

   Twenty minutes later the stridor is louder; SpO2 86% on a non-rebreather and she can't finish sentences. What do you do?

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   • Progressive stridor despite treatment: she needs a tube now, in theatre, with ENT scrubbed. Crisis
   • Wound reopened first if there's any swelling, to take pressure off her airway.
   • Awake intubation, sitting up, topical lidocaine, total capped at 9 mg/kg of lean weight. Airway
   • Sedation tiny and titrated; she keeps breathing on her own throughout.
   • A videolaryngoscope and smaller tubes ready as the next step.
   • Once the tube is in, she stays intubated in ICU until the swelling settles. After surgery
   • Extubation later only when a cuff leak has returned; a low leak predicts obstruction again.

4. Crisis

   During the attempt she obstructs completely. SpO2 is 70% and you cannot ventilate by mask. What now?

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   • DAS failed airway: total obstruction, SpO2 70%, and mask ventilation has failed. Crisis
   • One supraglottic airway attempt and a final two-person mask try, with full relaxant and depth.
   • Still no oxygenation: I say out loud 'can't intubate, can't oxygenate' and assign roles.
   • Full-dose relaxant, maximal neck extension if her fusion allows, then front-of-neck access.
   • Through the cricothyroid membrane: number 10 scalpel, then bougie, then a 6.0 tube railroaded over it.
   • Capnography confirms the tube, then ICU, and a debrief for the team. After surgery