Coroner’s clot
OVERVIEW
The ‘Coroner’s clot’ is an occult clot of blood remaining in the nasopharynx behind the soft palate following local surgery or trauma that has the potential to cause fatal airway obstruction following extubation/ removal of a supraglottic airway device (SAD)
- So named as the clot is traditionally discovered on post-mortem examination
- This was the cause of one death in the NAP4 study: “In one case, an inhaled blood clot after tonsillectomy produced total tracheal obstruction which was initially attributed to asthma and led to fatal cardiac arrest.”
RISK FACTORS
A ‘Coroner’s clot’ may be present in supine patients following:
- ENT or maxillofacial surgery (classically adenoidectomy or tonsillectomy)
- ENT or maxillofacial trauma
- Epistaxis
MANAGEMENT
Prior to extubation/ removal of SAD
- anticipate this potential complication in ‘at risk’ intubated patients
- ensure removal of all packs prior to extubation
- pass a suction catheter down both nares and suction the nasopharynx, oropharynx and above the glottis; the tip may be turned through 180 degrees to suction behind the soft palate under direct vision with a laryngoscope
- nasoendoscopy to visualise the nasopharynx, thus excluding remaining clots, is the gold standard
- perform laryngoscopy to exclude clots above the glottis; neck flexion during laryngoscopy may help cause any clot behind the soft palate to fall into view prior to extubation
After to extubation/ removal of SAD
- treat airway obstruction if it occurs (see airway obstruction)
- monitor for ongoing bleeding
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Journal articles
- Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011 May;106(5):617-31. [pubmed]
- Yap AJ, Lannigan FJ. Risk of ‘Coroner’s clot’ from the use of laryngeal mask airway during oropharyngeal surgery. ANZ J Surg. 2016;86(9):734-5. [pubmed]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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