Failed Tracheotomy Management

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Failed TracheotomyManagement

• Timothy M. McCulloch, MD
• University 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 visualized
• Very swollen epiglottis and arytenoids
• Very 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 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

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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 planned
• DID NOT RECOGNIZE SUPRAGLOTTIS

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Intubation 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

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Tracheotomy

• 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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ICU

• Morphine
• 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 vent tubing
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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 makes it impossible to fit
back into 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 called
• DID NOT RECOGNIZE DISPLACED TUBE
• ADDS TO PROBLEM BY BAGGING PATIENT

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Forced ventilation leads to subcutaneous air,
pneumothorax Failed exhalation, no inhalation
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ER 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

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PATIENT DIESFORGOT ABCs
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NO egressTies not places or too
looseUnrecognized displacementtube too
shortPoor balloon managementPatient fighting
vent,coughing, moving, pulling on tubesFORGOT
ABCs
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2 cm fat, 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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Direct Visualization
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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 tube
• Early and Late
• Tracheotomy site bleeding
• Granulation tissue, wound edges, major artery
  bleeds
• Bleeding post suctioning
• Balloon leaks and tracheomalacia
• Chronic high pressure

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THANK YOU

• Tim