Trach Tubes--Case

[SleepIsGood]

So I was with the Anesthesiology Attending making some 'rounds' with post-op patients we had taken care of yesterday.

As we entered the room a nursing student was present in the room already by the pt's bedside. Please keep in mind that the pt is a 60 s/p Laryngectomy, Pharyngectomy (had Ca of Larynx). At any rate the pt had a trach that was put in yest.
Clearly, not enough time for the trach/stoma to epithelize a tract etc.

At any rate, nursing student was doing here nl stuff checking drains,etc. All of a sudden she removed the trach to look at the stoma. BAAM, stoma is almost shut tight. Pt is gasping for air. What do you do? And no...changing your diapers is not an option.

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[MirrorTodd]

Bump-I'm interested in hearing about this.

 

[Noyac]

Grab the stylet taped to the head of the bed, put it into the trach tube, push down on the chest. When you see air escape from the ostomy site drive the trach back in.
Never had to so this but it s what I came up with on short notice. I'm sure there are better ways.

 

[SleepIsGood]

Grab the stylet taped to the head of the bed, put it into the trach tube, push down on the chest. When you see air escape from the ostomy site drive the trach back in.
Never had to so this but it s what I came up with on short notice. I'm sure there are better ways.

by stylet do you mean obturator? and I'm assuming by ostomy site you are referring to the stoma site?

That's definitely an option that I was thinking of initially too. The only thing is the possibility of creating a false passage.

 

[militarymd]

that might be a lift ending mistake.


some sort of stylet/obturator to get the tube back in is the only hope....bronchoscope can be used.

 

[Noyac]

by stylet do you mean obturator? and I'm assuming by ostomy site you are referring to the stoma site?

That's definitely an option that I was thinking of initially too. The only thing is the possibility of creating a false passage.

Uhhhhh, yeah thats what I meant. Glad you could decipher it.

 

[Noyac]

that might be a lift ending mistake.


some sort of stylet/obturator to get the tube back in is the only hope....bronchoscope can be used.

lift?

 

[militarymd]

lift?

life

 

[cchoukal]

Having just spent a month as an intern on the ENT service, I will second the "life-ending mistake" comment. This happened in our hospital this year. In folks with trachs for vent dependence (read: near-normal airway), some ENTs recommend intubating from above, rather than risk intubating the mediastinum. In someone s/p laryngectomy, you're pretty much screwed and have to intubate the stoma. If bronchoscope not IMMEDIATELY available, and it were just me in the room, I guess I'd intubate the stoma and pass a flexible suction catheter to try to confirm placement, while paging ENT overhead, STAT.

 

[Noyac]

life

Thought so

 

[Mike MacKinnon]

You would be limited to whats in the room.

Chances of getting intubation equipment fast enough are nil.

Grab the yankauer put the buisness end in through the origional stoma. grab the bag and place it over the yankauer with a glove wrapped around it to maintain some seal. No you wont be ventilating, you will be oxygenating (ala needle cric).

That will keep the patient alive long enough to get a 1 miller, place it in the stoma use a normal intubation technique and reintubate with the shiley. The 1 miller allows you to lift and avoid false passage. Its the same way i place tubes after i cric.

while not exactly under these circumstances (i was in the field), ive done something similar