May 29, 2019

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)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 12.0 – Tracheostomy Emergencies", REBEL EM blog, May 29, 2019. Available at: https://rebelem.com/rebel-core-cast-12-0-tracheostomy-emergencies/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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