Failed TracheotomyManagement
Timothy M. McCulloch, MDUniversity of Washington
Harborview HospitalOtolaryngology
Case Report
35 year old male arrives in ER complaining of Sore throat and swallowing troubleER Doctor finds no Neck mass or oral cavity irregularity CXR clearCalls Otolaryngology Doctor (1 hour in response)
Continued case one
Oxygen saturation 99%After 50 minutes the patient complains of Shortness of breathAnesthesiology Called (10 minutes)Retracting, stridor Intubation planned
Intubation attempt
Patient paralyzed Airway visualizedVery swollen epiglottis and arytenoidsVery erythematous bleeding started
Oxygen sat drift downOtolaryngologist reaches ER-Crash Tracheotomy begun
Tracheotomy
Tracheotomy completed6 cuffed Shiley tracheotomy tube placedTied with tracheotomy ties no sutures placedPatient now awake / responsiveAdmitted to ICU
ICU
Morphine Sedation with VersedVentilator setting ordered RATE 12 Volume 700 cc
6 hours laterMidnight
Patient awakeVoices complaint about painFeels short of breathNurse call RT about “leak around tube”
RT and Nurse
Add air to tracheotomy tubePatient medicated for “anxiety”
Shit hits the fan
Patient become more agitatedOxygen saturations dropRemoved from ventilator bagged by HandSaturations dropCode called
ER doc reaches bedsidePatient blueUnresponsiveCPR startedSub-cutaneous air in neck and chestNeedles placed in chest to treat pneumothoraxTracheotomy 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 troubleER Doctor finds no Neck mass or oral cavity irregularity CXR clearCalls Otolaryngology Doctor (1 hour in response)DID NOT RECOGNIZE SUPRAGLOTTISSLOW RESPONSE BY SPECIALIST
Continued case one
Oxygen saturation 99%After 50 minutes the patient complains of Shortness of breathAnesthesiology 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 downOtolaryngologist 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 VersedVentilator setting ordered RATE 12 Volume 700 cc
POOR MANAGEMENT OF AWAKE PATIENTOXYGEN Supplementation or Total Airway control
6 hours laterMidnight
Patient awakeVoices complaint about painFeels short of breathNurse call RT about “leak around tube”DID NOT RECOGNIZE DISPLACED TUBE
Weight of venttubing
RT and Nurse
Add air to tracheotomy tube cuffPatient medicated for “anxiety”DID NOT RECOGNIZE DISPLACED TUBEADDS TO PROBLEM BY ADDING AIR
Additional air makesit impossible to fit backinto trachea
Shit hits the fan
Patient become more agitatedOxygen saturations dropRemoved from ventilator bagged by HandSaturations dropCode calledDID NOT RECOGNIZE DISPLACED TUBEADDS TO PROBLEM BY BAGGING PATIENT
Forced ventilation leadsto subcutaneous air, pneumothoraxFailed exhalation, no inhalation
ER doc reaches bedsidePatient blueUnresponsiveCPR startedSub-cutaneous air in neck and chestNeedles placed in chest to treat pneumothoraxTracheotomy tube removed replaced with endotracheal tube - ventilation failsDID NOT RECOGNIZE DISPLACED TUBEADDS 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 visionMask 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-sedatedQuadriplegicRestrainedRecent unit transfersObesePoor lung functionCardiac problemsHeparinized
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