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Sentinel bleeds and carotid blowout
Overview
Bleeding or hemorrhage in patients with head and neck cancer is a relatively frequently encountered consultation at tertiary care centers. In most cases, bleeding may be limited or spontaneously resolve, but patients should be thoroughly evaluated to determine the site and source of bleeding as limited sentinel bleeding can be a sign of a more sinister developing problem. While large volume head and neck bleeds from carotid artery injury (i.e., carotid blowout) is relatively uncommon, this catastrophic complication may be heralded by a lower volume or “sentinel” bleed and thus should be considered in all cancer patients with predisposing tumors or prior radiation treatment. Risk factors for major head and neck bleeding include those which compromise the vasa vasorum and adventitia of the carotid such as: prior radiation therapy, prior surgical intervention nearby (e.g. neck dissection), residual or recurrent cancer, infection, and mucocutaneous fistula. A true carotid blowout carries a high mortality rate even if occurring in the hospital and is almost universally fatal if occurring outside the hospital setting.
Carotid blowouts may be categorized as threatened (evidence on imaging or exam of risk of a blowout without any bleeding), impending (self-limited bleed), and as an active blowout. In addition to carotid blowout, significant or even fatal bleeding may occur from the lingual artery, other branches of the external carotid, the jugular vein, or from a tumor directly. Principles of management for these consults includes appropriate triage, thorough examination, identifying the patients at risk for potentially catastrophic bleeding, and prophylactic treatment of these patients. Treatment typically involves securing an airway, tamponading acute bleeding if possible, and addressing problematic arterial bleeds with endovascular embolization or stenting. In some cases, especially in major venous bleeding, emergent surgical ligation may be employed. Tracheoinnominate fistula with tracheostomy or laryngectomy stoma bleed is covered in a separate section, entitled “Tracheostomy bleed”.
Key supplies for sentinel bleed consultation
Headlight
Eye protection, mask, gown, gloves
Flexible fiberoptic endoscope
Suction with Yankauer tip
Tongue depressor
Airway cart, complete with cuffed endotracheal tube assortment, and tracheostomy tray
Throat packing supplies (kerlix rolls x4, Kelly / tonsil clamp)
Ability to quickly activate the rapid response system to readily have help if you need it
Management
Large Volume Active Bleeding
Upon consultation, ensure large bore IV access x2, airway / crash cart availability, telemetry and pulse oximetry. Notify embolization team of possible emergent case
Upon arrival, assess patient status and ABC’s
In acute upper aerodigestive hemorrhage, mortality is primarily related to asphyxiation rather than hypovolemic shock, therefore, a priority is placed to securing an airway early. If bleeding is from a presumed upper aerodigestive source (e.g., per mouth):
Identify specific location of bleeding, if possible
Set up two large bore suctions if possible
Arrange for airway securement
Ensure airway cart is available and stays with patient
Ensure patient is positioned upright with suctions to aid in protecting airway
Patients with an unstable airway should be orotracheally or nasotracheally intubated; however, this is preferably done in a more controlled setting in the OR when possible
If patient is unable to protect airway and actively decompensating, intubation at bedside may be necessary
If unable to secure airway via orotracheal intubation, then surgical cricothyrotomy or tracheostomy should be performed for definitive airway control
Once airway is secured, place a throat pack to compress bleeding source, packing should be tight and initial rolls should go down to hypopharynx if possible, usually takes 3-4 kerlix rolls
Consider going to the OR for direct laryngoscopy vs transfer to IR for embolization
If bleeding is external
Compression to stop bleeding while arranging for definitive treatment; may be best accomplished by a gloved finger with precise pressure as indiscriminate pressure with dressings may simply hide the bleeding
Treat hypotension typically in concert with anesthesia or emergency department providers assistance; may require transfusions and vasopressors
Have a colleague work on arranging for immediate OR or IR transfer for exploration or ligation as indicated based on the involved vessels, patient stability, and facility capabilities
Labs
Type and cross patient or activate massive transfusion protocol as indicated
Obtain coagulation panel, correct anticoagulant status if indicated and possible
Low Volume or Self-Limited Bleeds
Assess all patients. Consulting providers may have low concern or underestimate the potential severity and call just as a courtesy call, these patients should all be evaluated urgently
Obtain complete history with attention to previous oncologic history and treatment as well as anticoagulant medications
Complete head and neck physical exam with nasopharyngoscopy. Try to identify source of bleeding, which may not be actively bleeding at time of examination. Signs of potential sources may include granulation tissue, areas of erosion or inflammation
Labs
CBC with consideration of type and screen
CMP with attention to renal function
Imaging
CTA
Evaluate for arterial wall necrosis, wall irregularity or stenosis, pseudoaneurysm formation, viable tumor burden, exposed artery, and active contrast extravasation
MRI with angiography
Rarely obtained due to length of study and need for extended supine positioning
Can be considered in stable patients under special circumstances
Consider IR consultation
Diagnostic and therapeutic angiography may be employed at discretion of the interventional radiologist with additional testing:
Contralateral carotid artery system angiography to determine patency of circle of Willis and if carotid sacrifice is possible
Balloon occlusion testing: If patient exhibits no clinical signs (neurologic exam performed during occlusion testing at set time intervals) or angiographic signs (<20% decrease in cerebral blood flow) of compromise, carotid embolism or ligation can be considered; stroke after carotid ligation is still possible in a portion of people who “pass” the balloon occlusion test
Stenting: may be employed to allow patency of injured artery (especially if common or internal carotid) while addressing bleeding. Length of artery injury and remainder vessel quality may not make this a viable option in many patients
Endovascular stenting, particularly for the common or internal carotid artery, is generally not a durable solution to the issue and should be seen as a bridge to more definitive management of the issue (e.g. surgical reconstruction of artery or coverage with vascularized tissue), as stent exposure and rebleeding is common over time
Embolization: if source is from the external carotid system or sufficient contralateral internal carotid flow, may be accomplished with wire vascular plugs, microparticles, wire coils, or permanent balloon (rarely)
Instructions for care team for all patients at risk of bleeding
Notify patient’s care team about the possibility re-bleeding and the steps to be taken in the event of bleeding:
Apply localized pressure to bleeding area
Call for aid and immediately notify ENT team
Have embolization team on standby if indicated
Disposition
If patient is extremely low risk for recurrent bleeding based on history, exam, and imaging (e.g. minor granulation tissue tracheostomy bleeding):
May consider overnight observation and discharge to home after discussion of return precautions
If patient is at moderate to high risk of recurrent bleeding or blowout based on history, exam, or imaging:
Consider admit to floor or ICU as indicated based on the overall risk and site of bleeding (intraoral bleeding may warrant higher level of care if concern of airway compromise with recurrence
Consider prophylactic treatment measures whether surgical or with interventional radiology endovascular treatments
Discharge is typically feasible after treatment and post-treatment observation period of various lengths based on what vessels are involved and the intervention taken (i.e. ICA embolization or jugular ligation would warrant at minimum overnight observation while endovascular embolization of a branch of the ECA may permit same day discharge in select situations)
Follow-up and Patient Instructions
Close follow-up with ENT typically within a week for most patients
Discuss return precautions and plan if rebleeding
If carotid blowout or other terminal bleed is possible and unable to be prophylactically treated (i.e. terminal patient with large segment carotid encasement unable to be stented) prepare patient and family members for possible blowout with plan in place in case of terminal bleeding: dark towels available, apply gentle pressure while attempting to keep patient calm
Goals of care conversation +/- palliative care conversation should be undertaken as indicated based on the situation to determine the patient’s and family’s wishes should bleeding occur (i.e. before bleeding if a patient is deemed high risk or in the “threatened bleeding category,” and after stabilization from a sentinel or major bleed)
References:
Medina, J.E., Vasan, N.R., (2013). Neck Dissection. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1807-1838). Baltimore, MD: Lippincott Williams & Wilkins.
Mydlarz, W.K., Eisele, D.W., (2020). Complications of Neck Surgery. In Flint, P.W., et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 1831-1839). Philadelphia, PA: Elsevier.
Suárez C, Fernández-Alvarez V, Hamoir M, et al. Carotid blowout syndrome: modern trends in management. Cancer Manag Res. 2018;10:5617-5628. Published 2018 Nov 13. doi:10.2147/CMAR.S180164
Manzoor NF, Pezaee RP, Ray A, Wick CA, Blackham K, Stepnick D, Lavertu P, Zender CA. Contemporary management of carotid blowout syndrome using endovascular techniques. Laryngoscope. 2017;127(2):383-90. doi: 10.1002/lary.26144