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Failed TracheotomyManagement
Timothy M. McCulloch, MDUniversity of Washington
Harborview Hospital
Otolaryngology
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Case 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)
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Continued case one
Oxygen saturation 99%
After 50 minutes the patient complains of Shortness of breath
Anesthesiology Called (10 minutes)
Retracting, stridor
Intubation planned
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Intubation attempt
Patient paralyzed
Airway visualizedVery swollen epiglottis and arytenoidsVery erythematous bleeding started
Oxygen sat drift down
Otolaryngologist reaches ER-Crash Tracheotomy begun
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Tracheotomy
Tracheotomy completed
6 cuffed Shiley tracheotomy tube placed
Tied with tracheotomy ties no sutures placed
Patient now awake / responsive
Admitted to ICU
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ICU
Morphine
Sedation with Versed
Ventilator setting ordered RATE 12 Volume 700 cc
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6 hours laterMidnight
Patient awake
Voices complaint about pain
Feels short of breath
Nurse call RT about “leak around tube”
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RT and Nurse
Add air to tracheotomy tube
Patient medicated for “anxiety”
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Shit hits the fan
Patient become more agitated
Oxygen saturations drop
Removed from ventilator bagged by Hand
Saturations drop
Code called
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ER doc reaches bedsidePatient 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
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PATIENT DIES
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REVIEW THE ERRORS
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Case 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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Continued case one
Oxygen saturation 99%
After 50 minutes the patient complains of Shortness of breath
Anesthesiology Called (10 minutes)
Retracting, stridor
Intubation plannedDID NOT RECOGNIZE SUPRAGLOTTIS
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Intubation attemptPatient paralyzed
Airway visualizedVery swollen epiglottis and arytenoidsVery erythematous bleeding started
Oxygen sat drift down
Otolaryngologist reaches ER-Crash Tracheotomy begun
PRIMARY TRACHEOTOMY PLAN WOULD HAVE BEEN BEST
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TracheotomyTracheotomy completed 6 cuffed Shiley tracheotomy tube placedSutures placed to close woundTied with tracheotomy ties no sutures placedPatient now awake / responsiveAdmitted to ICUOR REVISION WOULD HAVE BEEN BESTTUBE MOST LIKELY TOO SMALLNO SUTURES PLACED TO ADD SECURITY SUTURES CLOSING WOUND - BAD IDEA
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ICUMorphine
Sedation with Versed
Ventilator setting ordered RATE 12 Volume 700 cc
POOR MANAGEMENT OF AWAKE PATIENT
OXYGEN Supplementation or Total Airway control
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6 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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Weight of venttubing
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RT and Nurse
Add air to tracheotomy tube cuff
Patient medicated for “anxiety”DID NOT RECOGNIZE DISPLACED TUBE
ADDS TO PROBLEM BY ADDING AIR
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Additional air makesit impossible to fit backinto trachea
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Shit hits the fan
Patient become more agitated
Oxygen saturations drop
Removed from ventilator bagged by Hand
Saturations drop
Code calledDID NOT RECOGNIZE DISPLACED TUBE
ADDS TO PROBLEM BY BAGGING PATIENT
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Forced ventilation leadsto subcutaneous air, pneumothoraxFailed exhalation, no inhalation
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ER doc reaches bedsidePatient 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 failsDID NOT RECOGNIZE DISPLACED TUBE
ADDS TO PROBLEM BY ADDRESSING CHEST
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PATIENT DIES
FORGOT ABCs
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NO egressTies not places or too looseUnrecognized displacement
tube too shortPoor balloon management
Patient fighting vent,coughing, moving, pulling on tubes
FORGOT ABCs
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2 cmfat, vessels, thyroid
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Thoughts 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.
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DirectVisualization
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Fiber optic visualization
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Replace the tube with something with greater options
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High Risk Patients
Semi-sedated
Quadriplegic
Restrained
Recent unit transfers
Obese
Poor lung function
Cardiac problems
Heparinized
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Other issues
Changing Tracheotomy tubeEarly and Late
Tracheotomy site bleedingGranulation tissue, wound edges, major
artery bleedsBleeding post suctioning
Balloon leaks and tracheomalaciaChronic high pressure
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THANK YOU
Tim