Trachy Emergencies
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My simple basic guide for dealing with the tracheostomy patient in the emergency department.
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Trachy Emergencies
- 1. Trachy Emergencies! By Kane Guthrie
- 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. 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. The Tube’s • Tracheostomy tubes are devices that aid passage of air into the lungs for effective respirations.
- 5. Trachy Emergencies Most 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. Anatomy
- 7. Indications! • To maintain the airway • To protect the airway • For bronchial toilet • For weaning from IPPV
- 8. Cautions & Contraindications • Difficult anatomy • Moderate coagulopathy • Proximity to site of recent surgery or trauma • Localised infection • Severe gas exchange problems Patients generally requiring an emergency trachy don’t have the luxury of having these conditions corrected before hand!
- 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.
- 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. 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. 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!
- 15. The Types 1. Cuffed and uncuffed 2. Fenestrated and unfenestrated 3. Those with inner cannulas and those without
- 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. Fenestrated Fenestrated: • 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. 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. The Size’s www.resusroom.com
- 20. Immediate Complications • Bleeding • Pneumothorax or pneumomedistinum • Injury to adjacent structures • Post obstructive APO
- 21. Early Complications • Bleeding RT - HT or coughing • Mucous Plugging • Tracheitis • Cellulitis • Displacement of tube- false passage • SubQ emphysema • Atelectasis
- 22. Late Complications • Swallowing problems • Tracheal stenosis • Tracheo-inominate artery fistula • Tracheoesophageal fistula • Granuloma formation
- 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. 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. 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. 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 8 What do you do?
- 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!
- 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. The Dislodged Trachy • Completely dislodged vs. false passage! • Most prevalent in newly created trachy! • Occurs with forceful coughing and poorly secured trachy.
- 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.
- 33. 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!
- 34. Questions?
- 35. References: • www.resusroom.com/ • SCGH- Tracheostomy Education package. • Hess, D. (2005). Tracheostomy Tubes and Related Appliances. Respiratory Care. 50(4), 497-510. • De Leyn, P. et.al. (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.