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