Symptomatic carotid stenosis for endarterectomy under cervical plexus block74-year-old woman, 64 kg, for urgent left carotid endarterectomy under cervical plexus block

The patient

The examiner asks

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1. Consider

   What matters in this patient?

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   • A 74-year-old with a recent stroke from left carotid stenosis, for urgent endarterectomy under a block. Patient
   • At 74 I record her baseline cognition, because awake monitoring depends on it.
   • Operating inside 2 weeks of her event gives most benefit; she shouldn't wait. Stem trigger
   • Heart attack around surgery is a leading killer after endarterectomy. Disease
   • Goals: protect heart and brain, steady pressure, and an awake patient for checks.

2. Prepare

   How do you assess her and perform the block?

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   • Several BP readings set her usual range, which becomes my target during clamping. Disease
   • Aspirin and cardiac drugs continue to the morning of surgery; provoking head positions are avoided.
   • She must communicate and tolerate drapes; language barriers or claustrophobia mean general anaesthesia. Patient
   • A superficial or intermediate block of the cervical plexus; deep blocks bring more complications and conversions. Surgery
   • Never bilateral deep blocks: phrenic palsy is common.
   • Near-toxic levels occur in half, so lidocaine top-ups stay within 7 mg/kg with adrenaline.
   • Arterial line, minimal sedation, tented drapes, a squeeze toy in her right hand, airway kit ready. Airway

3. Plan

   Talk me through clamping and her recovery.

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   • A 2–3 minute test clamp while I check speech, alertness and right-hand grip. Surgery
   • Her BP kept 10–20% above baseline during the clamp. Disease
   • Baroreceptor bradycardia: surgeon stops and infiltrates 1% lidocaine at the bifurcation. Surgery
   • Afterwards BP held near her baseline; high pressure risks haematoma and hyperperfusion. After surgery
   • Hyperperfusion shows as headache, seizure or focal signs, usually days later.
   • Close monitoring for 8 hours or more, since most problems surface then.

4. Crisis

   Two minutes into the test clamp she becomes confused and her right grip weakens. BP 158/88. What do you do?

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   • Cerebral ischaemia from the clamp: tell the surgeon now. (Crisis)
   • Raise her BP with phenylephrine 50–100 mcg to push collateral flow.
   • No quick recovery: the surgeon places a shunt.
   • Oxygen and reassurance; if she seizes or loses consciousness, I convert to general anaesthesia.
   • Converting under drapes: supraglottic airway or tube, surgeon holding the open wound.

5. Crisis

   Ninety minutes later in recovery her neck swells quickly, she has stridor and SpO2 is 88%. What do you do?

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   • Expanding haematoma compressing her airway: surgeon and senior help called now. Crisis
   • Cut the sutures and open her wound right there in recovery, releasing the clot.
   • Sit her up, 100% oxygen, and prepare for a difficult intubation.
   • Intubate after decompression with a videolaryngoscope, small tubes, and front-of-neck kit open. Airway
   • Back to theatre to find the bleeding point, then tight BP control. After surgery