Title: Failed Tracheotomy Management
1Failed TracheotomyManagement
- Timothy M. McCulloch, MD
- University of Washington
- Harborview Hospital
- Otolaryngology
2Case Report
- 35 year old male arrives in ER complaining of
Sore throat and swallowing trouble - ER Doctor finds no Neck mass or oral cavity
irregularity - CXR clear
- Calls Otolaryngology Doctor (1 hour in response)
3Continued case one
- Oxygen saturation 99
- After 50 minutes the patient complains of
Shortness of breath - Anesthesiology Called (10 minutes)
- Retracting, stridor
- Intubation planned
4Intubation attempt
- Patient paralyzed
- Airway visualized
- Very swollen epiglottis and arytenoids
- Very erythematous bleeding started
- Oxygen sat drift down
- Otolaryngologist reaches ER-
- Crash Tracheotomy begun
5Tracheotomy
- Tracheotomy completed
- 6 cuffed Shiley tracheotomy tube placed
- Tied with tracheotomy ties no sutures placed
- Patient now awake / responsive
- Admitted to ICU
6ICU
- Morphine
- Sedation with Versed
- Ventilator setting ordered
- RATE 12
- Volume 700 cc
76 hours laterMidnight
- Patient awake
- Voices complaint about pain
- Feels short of breath
- Nurse call RT about leak around tube
8RT and Nurse
- Add air to tracheotomy tube
- Patient medicated for anxiety
9Shit hits the fan
- Patient become more agitated
- Oxygen saturations drop
- Removed from ventilator bagged by Hand
- Saturations drop
- Code called
10ER doc reaches bedside
- Patient blue
- Unresponsive
- CPR started
- Sub-cutaneous air in neck and chest
- Needles placed in chest to treat pneumothorax
- Tracheotomy tube removed replaced with
endotracheal tube - ventilation fails
11PATIENT DIES
12REVIEW THE ERRORS
13Case Report
- 35 year old male arrives in ER complaining of
Sore throat and swallowing trouble - ER Doctor finds no Neck mass or oral cavity
irregularity - CXR clear
- Calls Otolaryngology Doctor (1 hour in response)
- DID NOT RECOGNIZE SUPRAGLOTTIS
- SLOW RESPONSE BY SPECIALIST
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15Continued case one
- Oxygen saturation 99
- After 50 minutes the patient complains of
Shortness of breath - Anesthesiology Called (10 minutes)
- Retracting, stridor
- Intubation planned
- DID NOT RECOGNIZE SUPRAGLOTTIS
16Intubation attempt
- Patient paralyzed
- Airway visualized
- Very swollen epiglottis and arytenoids
- Very erythematous bleeding started
- Oxygen sat drift down
- Otolaryngologist reaches ER-
- Crash Tracheotomy begun
- PRIMARY TRACHEOTOMY PLAN WOULD HAVE BEEN BEST
17Tracheotomy
- Tracheotomy completed
- 6 cuffed Shiley tracheotomy tube placed
- Sutures placed to close wound
- Tied with tracheotomy ties no sutures placed
- Patient now awake / responsive
- Admitted to ICU
- OR REVISION WOULD HAVE BEEN BEST
- TUBE MOST LIKELY TOO SMALL
- NO SUTURES PLACED TO ADD SECURITY
- SUTURES CLOSING WOUND - BAD IDEA
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19ICU
- Morphine
- Sedation with Versed
- Ventilator setting ordered
- RATE 12
- Volume 700 cc
- POOR MANAGEMENT OF AWAKE PATIENT
- OXYGEN Supplementation or Total Airway control
206 hours laterMidnight
- Patient awake
- Voices complaint about pain
- Feels short of breath
- Nurse call RT about leak around tube
- DID NOT RECOGNIZE DISPLACED TUBE
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22Weight of vent tubing
23RT and Nurse
- Add air to tracheotomy tube cuff
- Patient medicated for anxiety
- DID NOT RECOGNIZE DISPLACED TUBE
- ADDS TO PROBLEM BY ADDING AIR
24Additional air makes it impossible to fit
back into trachea
25Shit hits the fan
- Patient become more agitated
- Oxygen saturations drop
- Removed from ventilator bagged by Hand
- Saturations drop
- Code called
- DID NOT RECOGNIZE DISPLACED TUBE
- ADDS TO PROBLEM BY BAGGING PATIENT
26Forced ventilation leads to subcutaneous air,
pneumothorax Failed exhalation, no inhalation
27ER doc reaches bedside
- Patient blue
- Unresponsive
- CPR started
- Sub-cutaneous air in neck and chest
- Needles placed in chest to treat pneumothorax
- Tracheotomy tube removed replaced with
endotracheal tube - ventilation fails - DID NOT RECOGNIZE DISPLACED TUBE
- ADDS TO PROBLEM BY ADDRESSING CHEST
28PATIENT DIESFORGOT ABCs
29NO egressTies not places or too
looseUnrecognized displacementtube too
shortPoor balloon managementPatient fighting
vent,coughing, moving, pulling on tubesFORGOT
ABCs
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342 cm fat, vessels, thyroid
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39Thoughts when dislodged tube suspected
- Deflate cuff and advance tube
- Bag gently and watch for chest rise
- Fell for resistance
- Watch for subcutaneous swelling and air.
- Remove and replace under direct vision
- Mask patient
- Unless there is an upper airway problem this
should work - Air should escape trach site cover with finger.
40Direct Visualization
41Fiber optic visualization
42Replace the tube with something with greater
options
43High Risk Patients
- Semi-sedated
- Quadriplegic
- Restrained
- Recent unit transfers
- Obese
- Poor lung function
- Cardiac problems
- Heparinized
44Other issues
- Changing Tracheotomy tube
- Early and Late
- Tracheotomy site bleeding
- Granulation tissue, wound edges, major artery
bleeds - Bleeding post suctioning
- Balloon leaks and tracheomalacia
- Chronic high pressure
45THANK YOU