Expanding neck haematoma after parathyroidectomy71-year-old woman, 64 kg, for parathyroidectomy for primary hyperparathyroidism with recurrent kidney stones

The patient

The examiner asks

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1. Consider

   What are your concerns before her parathyroidectomy?

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   • A 71-year-old with a 4-month-old drug-eluting stent on dual antiplatelets, for parathyroidectomy. Patient
   • At 71, a neck bleed on two antiplatelets or a stent clot off them would both hit her hard.
   • ACC/AHA, applied to her: the surgeon calls it time-sensitive, so her stent sets the timing. Stem trigger
   • No active cardiac condition; RCRI 1 for her angina; two flights of stairs is over 4 METs. Disease
   • Purely elective parathyroidectomy would wait until 6 months after her stable-angina DES.
   • We operate at 4 months only because it's time-sensitive, agreed with cardiology.
   • DAPT continued if bleeding allows; aspirin never stops.

2. Crisis

   In recovery, 40 minutes after extubation, her neck swells quickly, her voice is hoarse and she is anxious. SpO2 93%, RR 26, BP 178/96. What do you do?

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   • Expanding neck haematoma: an airway emergency; I call the surgeon and my senior now. Crisis
   • Sit her up, 100% oxygen, airway trolley.
   • Open the wound here in recovery: skin sutures cut, muscle layer opened, clot lifted out.
   • Then theatre to find the bleeder; no induction before her wound is open.
   • Still obstructed: awake intubation if she cooperates, keeping her breathing on her own. Airway
   • Videolaryngoscope first, smaller tubes, and scalpel–bougie–tube ready.

3. Crisis

   Next morning she has tingling around her mouth and fingers. Calcium is 7.2 mg/dL; QTc 500 ms. What do you do?

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   • Symptomatic hypocalcaemia after parathyroidectomy, likely hungry bone after her hyperparathyroidism is corrected. Crisis
   • Calcium gluconate 10%, 10–20 mL at 5 mL/min, then a continuous infusion.
   • Cardiac monitoring: low calcium lengthens her QT and weakens contraction.
   • I watch for stridor; low calcium can itself cause laryngeal stridor.
   • Magnesium checked too, because low magnesium keeps calcium low.
   • Levels repeated every few hours; endocrinology starts oral calcium plus vitamin D. After surgery

4. Plan

   What about her antiplatelets and blood products?

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   • Platelets if she keeps bleeding: clopidogrel leaves them working poorly despite a normal count. (After surgery)
   • Aspirin never stopped, protecting her stent through all of this.
   • Clopidogrel restarts once the surgeon is happy with the wound, agreed with cardiology.
   • Chest pain or ST change means stent thrombosis until proven otherwise; cardiology now.
   • I explain the haematoma to her and her family; a bleed on DAPT goes to incident review.