Hi Everyone and Happy Tuesday!
I am here to officially introduce myself as this block’s Admin Resident! If we haven’t had the chance to meet- my name is Kaitlyn DeStefano, one of the third year residents and I have the misfortune of following the great Dan Ye, so though my POTDs will not nearly be as amazing, I will sure try. Without further delay, I want to tell you all about a case I was peripherally involved with this weekend, the wonder Dr. Mara Zafrina primarily saw and highlight some learning points I took away.
Its Sunday afternoon, Palm Gardens has sent over its fifth trach to vent patient to Northside and we get the pre-notification for a stable trach to vent patient who’s chief complaint is bleeding from the trach. The patient arrives and EMS looks a bit panicked because- no no, this is not a stable patient, the patient is saturating in the 70s and had a little episode en route with some bradycardia though they adjusted the bag to the trach and it picked up but nonetheless, here they are standing in the hallway outside of 52.
Before the patient even gets slotted into a location, Dr. Zafrina starts with listening to the lungs, “bilateral lung sounds” but also “feels like there is some subcutaneous air”. Okay- that’s weird. Also the patient’s face looks a bit swollen, but I dont know who this lady is- maybe thats normal for her, they get her into 52 and the show really gets started.
The patient has saturations in the 60-70s. The patient has subcutaneous air extending around the chest into the face, eyelids, tongue, and around the mouth. The patient is starting to become more and brady with HRs dipping into the 30s and 20s. Yogi, the respiratory therapist helping us, is having a difficult time bagging the patient is meeting a lot of resistance and there is a ton of air coming from around the trach. Dr. Aghera attempts to re inflate the balloon, replace the trache bedside, once with inner cannula, once with a new trache and still the patients HR is in the 20s, we have no saturation on the monitor and the patient is becoming cyanotic. Desperate, I paged thoracic and begged for anyone to come help us. Dr. Zach Cohen replies, “get the bronch ready” and before we know it the surgical senior, junior, intern are all at bedside, shortly followed by Dr. Caifa. They drop the bronch- there are no tracheal rings, no carina. And also now, no pulse. ACLS is initiated. An airway is established from before with an endotracheal tube. ACLS continues, patient continues to be pulseless, and b/l chest tubes are placed, finally ROSC is achieved.
Man- I knew to be scared of traches but I had NO idea how quickly this could go sour and how scared I would be in these moments even as a bystander. I thought I would do a deep dive into tracheostomies and how to troubleshoot. As good ED staff the hallmark to any unstable patients is to go back to the basics:
Airway:
Apply supplemental to both the mouth/nose AND the stoma
Both can be done with a non rebreather
Determine the age of the tracheostomy and the patency of the airway above it
In this patient’s case I did a quick chart check and could not see when the trache was placed but could see during the patient’s January admission she was on nasal cannula only so it was at most 2 months old
If there is bleeding at the tracheostomy: Concern for tracheo-innominate artery fistula
Over inflate the balloon to tamponade the bleed OR
Apply direct pressure with your fingers at the site of the bleeding
Tracheostomy obstruction:
Common problem: Mucus plugging
Attempt to resolve with passing a flexible suction
May need to remove the inner cannula and suction the outer cannula
Attempt to ventilate when deflating the cuff
If unable to fix, remove the tracheostomy
Tracheostomy Decannulation: Bingo! This was our problem
Occurs with partial or complete displacement
Can assess for this by:
Attempting to pass flexible suction
Connect end tidal to the tracheostomy
Attempt to pass a bronchoscopy for direct visualization
You should start to suspect a false passage if subcutaneous emphysema occurs
Establish a definitive airway through direct visualization either above the tracheostomy or through visually directed bronchoscopy
Breathing:
If bag valve mask ventilation is needed:
Apply a bag mask valve over the mouth and nose and cover the tracheostomy stoma with a wet gauze OR
Apply a bag mask valve over the tracheostomy stoma and cover the mouth and nose
In this patient, I suspect that the patient had such significant subcutaneous emphysema that was worsened by continued positive pressure ventilatory systems which increased high peak pressures, worsening barotrauma, and expanding pneumothoraces, to the point of causing cardiac arrest!
And with that- I will leave you this nightmare fuel until we talk again!