REBEL Core Cast 12.0 – Tracheostomy Emergencies

Take Home Points on Tracheostomy Emergencies

Track is mature in 7 days – don’t blindly replace before then because concern for false track creation

All bleeding needs to be taken seriously and should be evaluated by surgery

If not ventilating through trach – go through it systematically to find malfunction

REBEL Core Cast 12.0 – Tracheostomy Emergencies

What is a trach?

Permanent or semi permanent airway BELOW the glottis. It is most commonly placed between 3rd and 4th tracheal rings into the trachea.

Trachs are placed for 4 MAJOR reasons:

Bypass glottic or supraglottic stenosis or obstruction

Tracheal toilet

Provide more comfortable airway for patients requiring prolonged ventilation

Protect from aspiration

Management:

Key Concept: Takes 7-10 days for tract to become mature. If >7 days out, can replace trach safely.

Obstruction and Dislodgement are the commonly seen complications in the emergency department

Dislodgement If trach greater than 7 days old you can simply replace it. Make sure you know patients current trach size. To replace trach, follow these simple steps Take new trach and load obturator Apply some lubrication to the trach Take trach and enter the stoma at 90 degree angle As trach passes skin angle it down, straight down into trach Once in place, pull obturator and place inner cannula If trach less than 7 days old do not replace because you could create false track. Use fiberoptic scope Get ENT or Surg involved to help with placement If trouble replacing trach you can bag through the stoma. Use LMA or Pediatric mask with BVM to supply oxygen. Bagging not working? Can’t replace the stoma? You gotta intubate from above.

Obstruction Address patient hypoxia -> supplemental O2 via mouth with 100% non-rebreather or assisted breaths with BVM Need to deflate cuff in order to get oxygen through Attempt to pass suction catheter. If unable to pass suction cath then trach or inner canula needs to be replaced.



Replacement trach:

Sometimes difficult to replace trach with same sized one, its ok to downsize.

You can replace with ETT, would recommend using 6.0 cuffed tube.

Bleeding Trach:

Mild bleeding at skin – likely local irritation. Treat with pressure and possibly silver nitrate

Bleeding from trach should be taken seriously, need to consider the life threatening tracheo-innominate fistula.

Due to trach eroding anteriorly causing abnormal connection between the trachea and the innominate or right subclavian artery.

Consult CT surgery, likely will need bronchoscopy

Temporizing measures while waiting for definitive treatment Over-inflate the cuff to tamponade bleeding Secure airway with endotracheal intubation Remove tracheostomy and insert a finger to compress innominate artery anteriorly



For More on This Topic Checkout:

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)