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

LITFL

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]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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