darkhorse
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A 71-year-old man is undergoing a coronary artery bypass procedure in the morning. He has a long-standing history of coronary artery disease and hypertension and takes atenolol, furosemide, captopril, and digoxin daily. The patient also suffers from moderate osteoarthritis of the cervical spine. You are called to insert the internal jugular central line that will be used during the case the following morning. It is difficult to get the patient in optimal position but the attempt is made at placing the line. After multiple attempts on the right, a successful left-sided internal jugular central venous catheter is placed. The position is confirmed by chest radiograph. Three hours later, the nurse calls because the patient is now stridorous. On arrival to the room, you notice that the patient is having difficulty breathing, has audible inspiratory stridor, and has a massively swollen right neck extending to the midline and to the clavicle inferiorly. The next step in the management of this patient is to
A. administer a bolus of furosemide, intravenously
B. apply pressure to the right side of the neck
C. call for a vascular surgeon emergently
D. give nebulized beta agonist therapy immediately
E. perform a bedside surgical opening of the neck
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| Justice
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C. call for a vascular surgeon emergently
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| Kamsi
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C Call for vascular surgeon
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| sonaliraj99
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plz explain y d answr is C..
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| darkhorse
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| darkhorse
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Explanation: The correct answer is C. All central line placements are associated with complications. The nature and incidence of those complications are site specific. For internal jugular lines, the incidence of carotid puncture is about 5%. Most of these are trivial since the puncture occurs with the small 19G or 22G seeker needle, but in patients where the anatomy is difficult, multiple attempts at line placement often mean multiple lacerations of the carotid. This patient has bled into his neck and has nearly compressed his trachea from the pressure of the contained blood (the blood is under pressure equivalent to his mean arterial pressure). A surgeon should be called immediately for either an emergency bedside opening and decompression, or to go to the operating room emergently.Since there is no evidence that this patient is in pulmonary edema, a bolus of intravenous furosemide (choice A) will not be helpful. Trying to apply pressure to the right side of the neck (choice B) is incorrect and could result in the collapse of the trachea. The bleeding has already stopped secondary to the tamponade effect of the closed space, any further extrinsic compression will only further compromise his airway.Similarly, giving nebulized beta agonist therapy (choice D) is not useful since the stridor heard is not due to bronchiolar spasm but to external compression of the extra-thoracic trachea. Performing a bedside surgical opening of the neck (choice E) should ONLY be attempted by an experienced vascular surgeon. This is because once the tamponade is relieved, the carotid will continue to bleed and unless hemostasis can be attained, the patient runs a severe risk of bleeding to death.
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