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:

• LITFL: Tracheostomy
• Crashing Patient: Traceostomy and Trach Emergencies
• Core EM: Tracheostomy Issues
• emDocs: Trach Travails
• emDocs : Management of Acute Respiratory Distress in a Tracheostomy Patient

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

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