Type 2 (impending) carotid blow out syndrome.

A 41-year-old male, a known case of metastatic neck nodal disease with unknown primary presented to palliative care outpatients with neck pain, deep seated neck ulcer and bleeding from the neck ulcer. Clinical examination revealed a wide, infected, foul smelling, necrotic ulcer extending from the nape of the neck posteriorly to the midline anteriorly. On deeper examination of the ulcer, there was continuous serosangious discharge, with minimal frank bleeding over the exposed carotids. Two satellite fungating wounds were noted over the right occiput and right clavicle [Figure 1]. Patient was managed conservatively with local hemostatic (Hemocoagulase) and Metronidazole dressing, systemic anaerobic cover and oral Tranexamic acid. Selective COX II inhibitor (Etorocoxib) and Tapentadol were used as analgesics. Family members were counseled about possible massive hemorrhage and educated about managing the crisis at home with simple interventions. Endovascular stenting and surgical interventions were deferred in view of advanced nature of the disease and poor socio-economic status.

Figure 1

Type 2 CBS image

Carotid blow out syndrome (CBS) is common in patients with head and neck cancer and infection, fungating tumors, surgery, and radiotherapy are common risk factors. CBS is classified into three types. Type 1 (Threatened CBS) occurs when carotid artery is exposed due to soft tissue breakdown. Type 2 (Impending CBS) occurs when exposed carotid artery has limited sentinel bleeding and Type 3 (Active CBS) occurs when there is active hemorrhage or carotid rupture.

In a palliative care setting patients with Type 1 and 2, CBS should receive an emergency care plan which should include dark colored linens/towels to cover and absorb blood (less distressing than seeing bright red blood on white linens); gloves, face/eye protection (in case of brisk arterial spraying), and other universal precautions. Suctioning equipment for clearing the mouth or tracheostomy of blood is desirable. Midazolam 5-10 mg intravenous (IV) can be given as a single shot if the patient has severe dyspnea or restlessness. The family should be counseled and educated about emergency planning and accessing help.