Failed TracheotomyManagement

Timothy M. McCulloch, MDUniversity of Washington

Harborview Hospital

Otolaryngology

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)

Continued case one

Oxygen saturation 99%

After 50 minutes the patient complains of Shortness of breath

Anesthesiology Called (10 minutes)

Retracting, stridor

Intubation planned

Intubation attempt

Patient paralyzed

Airway visualizedVery swollen epiglottis and arytenoidsVery erythematous bleeding started

Oxygen sat drift down

Otolaryngologist reaches ER-Crash Tracheotomy begun

Tracheotomy

Tracheotomy completed

6 cuffed Shiley tracheotomy tube placed

Tied with tracheotomy ties no sutures placed

Patient now awake / responsive

Admitted to ICU

ICU

Morphine

Sedation with Versed

Ventilator setting ordered RATE 12 Volume 700 cc

6 hours laterMidnight

Patient awake

Voices complaint about pain

Feels short of breath

Nurse call RT about “leak around tube”

RT and Nurse

Add air to tracheotomy tube

Patient medicated for “anxiety”

Shit hits the fan

Patient become more agitated

Oxygen saturations drop

Removed from ventilator bagged by Hand

Saturations drop

Code called

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

PATIENT DIES

REVIEW THE ERRORS

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

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

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

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

ICUMorphine

Sedation with Versed

Ventilator setting ordered RATE 12 Volume 700 cc

POOR MANAGEMENT OF AWAKE PATIENT

OXYGEN Supplementation or Total Airway control

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

Weight of venttubing

RT and Nurse

Add air to tracheotomy tube cuff

Patient medicated for “anxiety”DID NOT RECOGNIZE DISPLACED TUBE

ADDS TO PROBLEM BY ADDING AIR

Additional air makesit impossible to fit backinto trachea

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

Forced ventilation leadsto subcutaneous air, pneumothoraxFailed exhalation, no inhalation

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

PATIENT DIES

FORGOT ABCs

NO egressTies not places or too looseUnrecognized displacement

tube too shortPoor balloon management

Patient fighting vent,coughing, moving, pulling on tubes

FORGOT ABCs

2 cmfat, vessels, thyroid

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.

DirectVisualization

Fiber optic visualization

Replace the tube with something with greater options

High Risk Patients

Semi-sedated

Quadriplegic

Restrained

Recent unit transfers

Obese

Poor lung function

Cardiac problems

Heparinized

Other issues

Changing Tracheotomy tubeEarly and Late

Tracheotomy site bleedingGranulation tissue, wound edges, major

artery bleedsBleeding post suctioning

Balloon leaks and tracheomalaciaChronic high pressure

THANK YOU

Tim