Trachy Emergencies


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My simple basic guide for dealing with the tracheostomy patient in the emergency department.

  • @kanegu thank you , I like to be one of your friends .
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  • @bishanrajapakse
    Hey Bish, Only just noticed your comment- my apologies.

    Great case, trachies certainly are challenging when your not exposed to them often enough.

    Hope all is well.

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  • Great talk Kane! Very informative- Also, I enjoyed the cases. Case 2 reminded me of one of my scariest medical experiences to date (which happened over 5 years ago when I was an ICU registrar (my first reg job) in a trauma hospital in NZ, and I had a patient who was a young adult. They were post op from trauma surgery, and soon after arriving in ICU they pulled out their tracheostomy as they were agitated. It was a really tricky situation, as there was blood everywhere, we had an agitated patient who still had a patient (but threatened) airway, and we had to decided whether to sedate the patient and compromise the airway further, or whether we could get away with just re-siting the tube then and there. We ended up getting ENT back to re-site the trachy, and they did it quickly and the outcome was good. However, if I had only known that they left sutures in the tracheal tissue that could be pulled upon to locate the lumen - life would have been much easier. (When the ENT reg arrived - she just, gloved up, tugged on the sutures that she had left in the operation and slid in a new trachy tube in easily) Cheers for the talk - Bish :)
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Trachy Emergencies

  1. 1. Trachy Emergencies! By Kane Guthrie
  2. 2. Objectives• A brief look at tracheostomy emergencies.• Indications for tracheostomy.• The different types of tracheostomy tubes.• Approach to the trachy emergency.• Case studies.
  3. 3. The Trachy!Tracheotomy: ‘is a surgical incision into the trachea for the purpose of establishing an airway”Tracheostomy ‘is the stoma (opening) that results from the tracheotomy”
  4. 4. The Tube’s• Tracheostomy tubes are devices that aid passage of air into the lungs for effective respirations.
  5. 5. Trachy EmergenciesMost common emergencies you will face: – Obstruction – Displacement• More Pt being D/C home with long term Trachies!= ED nurses need to know what to do when things go wrong!!
  6. 6. Anatomy
  7. 7. Indications!• To maintain the airway• To protect the airway• For bronchial toilet• For weaning from IPPV
  8. 8. Cautions & Contraindications • Difficult anatomy • Moderate coagulopathy • Proximity to site of recent surgery or trauma • Localised infection • Severe gas exchange problemsPatients generally requiring an emergency trachy don’t have the luxury of having theseconditions corrected before hand!
  9. 9. Patient Benefits!• Less risk of long-term airway damage.• Patient comfort – no tube in mouth!• Some can eat & talk!• Tube more secure some patients can mobilise.
  10. 10. The Types!Surgical:Percutaneous:
  11. 11. Surgical• Normally done electively (ICU,OT)• Can be done @ bedside (emergently)• 3-5cm incision 1 cm below cricoid• Done under general or local anaesthetic.Procedure – Dissection down to the trachea, surgical incision is made in “T” shape, between 2nd& 3 rd tracheal rings.
  12. 12. Percutaneous• Done in emergency circumstance where theater is not an option.Procedure: – No surgical incision required- opening is made via percutaneous “stab” into trachea.
  13. 13. Emergency• Emergency circumstance requiring extreme measure to secure the airway• Cricothroidotomy• Procedure: – Percutaneous stab into trachea to provide an opening and allow ventilation. – Scalpel-bougie, Scalpel –finger, Ball point pen!
  14. 14. The TypesCuffed:Uncuffed:
  15. 15. The Types1. Cuffed and uncuffed2. Fenestrated and unfenestrated3. Those with inner cannulas and those without
  16. 16. Cuffed Vs Uncuffed• Used initially • Used long term• Reduces aspiration, • Pt needs reasonable foreign matter in bulbar function to clear airway. own secretions• Prevents air escape in MV.• Cuff pressure 15- 25mmHg.• Use in emergencies!
  17. 17. FenestratedFenestrated:• Has pre-cut opening in posterior aspect of tube.• Facilitates air entry through the tube and allows speech.• Has 2 tube’s one that allows suctioning, eating & during sleep, the other allows talking.
  18. 18. Inner cannula• Have an inner tube that allows removal if becomes obstructed to allow removal & cleaning• Reduce potentially life threatening complications.• Increases the WOB.
  19. 19. The Size’s
  20. 20. Immediate Complications• Bleeding• Pneumothorax or pneumomedistinum• Injury to adjacent structures• Post obstructive APO
  21. 21. Early Complications• Bleeding RT - HT or coughing• Mucous Plugging• Tracheitis• Cellulitis• Displacement of tube- false passage• SubQ emphysema• Atelectasis
  22. 22. Late Complications• Swallowing problems• Tracheal stenosis• Tracheo-inominate artery fistula• Tracheoesophageal fistula• Granuloma formation
  23. 23. When to Suction?• Course breath sounds (crackles)• Noisy Breathing• ∧or ∨ resp rate• ∨ Sp02• Copious secretions• Pt attempting but unable to cough or clear secretions• Distressed or agitation
  24. 24. Factors that can Contribute to Emergencies!• Overproduction of sputum• Coughing• Irritation of the trachea• Undue movement of the tube• Multiple suctioning attempts• Dry, hardened secretions –sputum plug• Cuff integrity compromised• Vomitus or aspiration of stomach contents
  25. 25. The Approach• Is the tracheostomy tube displaced or obstructed?• Is the tube cuffed or uncuffed?• How old is the tract?• What is the size of the tube?• Why was the tube placed?
  26. 26. Case 1• 28 male P1 ambulance• Known Quad with long term trachy.• P/C: ?Blocked trachy• 0/A: Cyanosed lips, not moving air.• V/S: Spo2 70%, HR 145, GCS 8What do you do?
  27. 27. Blocked Trachy• Apply O2 to mouth and trachy• Try Suctioning – remove inner cannula.• Partial occlusion use saline Nebs, humidification, suctioning.• If fail try BVM – push down occlusion into lungs.• Change trachy tube or re-intubate!
  28. 28. The Blocked Trachy
  29. 29. Case 2• 74 male known throat ca• Long term trachy - fenestrated• P/C Trachy fallen out• O/A: Mild resp distress, unable to talk/• V/S: RR 22, Spo2 90%, Bp 138/84,• What do you do?
  30. 30. The Dislodged Trachy• Completely dislodged vs. false passage!• Most prevalent in newly created trachy!• Occurs with forceful coughing and poorly secured trachy.
  31. 31. The Dislodged Trachy• Replace with same size or smaller.• May need trachy dilators and bougie to assist.• Trachy set not available use small ETT.• Check correct placement – pass suction catheter, Etco2, clinical improvement, auscultation, CXR.• R/F to ENT.
  32. 32. Take Home Points• Trachy emergencies generally uncommon!• Have an approach!• Know how to suction!• Provide O2 to trachy and to mouth if distressed!• Always change to cuffed tube in emergencies!• Same size or smaller or just use an ETT!
  33. 33. Questions?
  34. 34. References:•• SCGH- Tracheostomy Education package.• Hess, D. (2005). Tracheostomy Tubes and Related Appliances. Respiratory Care. 50(4), 497-510.• De Leyn, P. (2007). Tracheotomy: clinical review and guidelines. European journal of Cardio-thoracic surgery. 412-421.• Jordan, S. & Gay, S. (2002).Tracheostomy Emergencies. American Journal of Nursing. 102(3), 59-63.
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