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


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:
The following two tabs change content below.

Anand Swaminathan

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

Latest posts by Anand Swaminathan (see all)

Like this article?

Share on facebook
Share on Facebook
Share on twitter
Share on Twitter
Share on linkedin
Share on Linkdin
Share on email
Share via Email

Want to support rebelem?

1 thought on “REBEL Core Cast 12.0 – Tracheostomy Emergencies”

Leave a Comment

Time limit is exhausted. Please reload CAPTCHA.