Tracheostomy Emergencies

When your patient has a tracheostomy, being prepared for the worst that could happen is crucial. There are three basics types of tracheostomy emergencies: occlusion, dislodgement and hemorrhage.

Tracheostomy Emergencies: Occlusion

Let’s say your patient has a trach, is on a trach mask and you heard in report that they have thick, copious secretions. Suddenly, the monitor alarm goes off, and you see that your patient’s O2 saturation has dropped to 62%. Whaaaaat? Knowing what you do about their thick secretions, you hurry in to the room pretty confident that you know what the problem is.

You see the patient struggling to breathe, squirming around in the bed and banging on the side rails as he mouths, “I can’t breathe, I can’t breathe.” So…what are you going to do about it?

Because he’s on a trach mask, he doesn’t have in-line suctioning. So, with one hand you crank up his oxygen as you quickly grab a suction kit with the other. You put on your sterile gloves (quickly!) and proceed to sterile suction your patient. You pull a thick glob of mucus from the trach and watch as your patient’s O2 saturation level climbs back up to 97%. Whew! That was a close one!

But what if you can’t get the occlusion cleared?

Sometimes, this happens. And it’s scary as heck. The first thing you should try is taking out the inner cannula and putting in a fresh one. Often times, this will do the trick! If the occlusion is further down (and not in the tube itself) you’ll need to call for help and start manually bagging your patient. In theory, this could push the occlusion further into the airway, but the chances of it occluding the entire airway further down is less severe than the fact that it is occluding the entire airway RIGHT NOW. Your patient will need a bronchoscopy to clear out that plug (and fluids, neb treatments to thin out those secretions so the patient can cough them up).

Tracheostomy Emergencies: Dislodgement

What if you’ve got a confused patient (or a child) who pulls out their entire trach? This is the stuff tracheostomy nightmares are made of. The most common reasons for accidental dislodgement are altered LOC, turning patients, copious secretions and poorly-secured trach ties.

If the entire trach comes out, you have two choices…put the tracheostomy tube back in or wait and see how they do. Sometimes, with a chronic trach that’s nice and open, the patient can breathe okay-ish through the stoma and you’ve bought yourself some time. If it’s a newer trach (and especially if the patient is vent dependent), you’re going to need to act fast!

Dislodgement with a chronic tracheostomy

Most trachs over 7 days old have healed sufficiently for the stoma to stay open if the trach is removed. Here’s what you’re going to do:

• Provide oxygen
• Monitor the patient for VS changes, increased WOB, signs of hypoxia
• Alert MD and RT
• Anticipate trach tube being replaced (hopefully you have supplies at the bedside!)
• If the patient shows signs of respiratory compromise…CALL A CODE!

Dislodgement with a fresh tracheostomy

Most likely, your patient with a fresh tracheostomy (less than 7 days old) will become unstable if a dislodgement occurs (after all, there’s a reason they have a trach in the first place!). Note that most fresh tracheostomies will be sutured in place…but this does not mean dislodgement can’t occur. And, of course, it is an EMERGENCY!

• Call a code
• Grab the Ambu-Bag and ventilate your patient
• If the trach is still sutured in place (and it probably is), cut the sutures and remove the tube
• The MD may try to reinsert the tracheostomy tube OR orally intubate the patient

Reinserting the tracheostomy tube

The supplies you need to reinsert the tracheostomy tube should be at the bedside at all times:

• Obturator that came with the patient’s current tracheostomy tube
• Spare tube (typically one-size down from current; maybe also the current size as well)
• Lubricant
• Syringe for inflating the cuff
• Foam trach ties for securing the new trach once it’s in place

To reinsert the tube, you’re going to use the obturator. Typically, the obturator that came with the patient’s trach will be taped to the wall at the head of the bed. This is so you can quickly grab it and reinsert the tube. Ideally, you’d want a clean, fresh tube…but if the current tube is the only one you have, get it in there and worry about changing it under more controlled conditions later 🙂

To reinsert your patient’s tracheostomy tube:

1. Remove the inner cannula (if it has one) from the new tube so you now just have the outer cannula.
2. If the cuff is inflated, deflate it (not all tubes have a cuff).
3. Place the obturator into the outer cannula.
4. Lubricate the tip of the outer cannula and the obturator to make insertion easier.
5. Place the outer cannula into the patient’s stoma.
6. Hold the tracheostomy tube in place by the flanges and remove the obturator.
7. Insert the inner cannula if your tube has one and inflate the cuff (if present).
8. Secure the tube with the trach ties.

If you are unable to insert the tracheostomy tube, try inserting one that is one-size smaller. If that doesn’t work, call the doc!

Tracheostomy Emergencies: Hemorrhage

One of the scariest things that can happen to your tracheostomy patient is a hemorrhage. It can be due to the formation of granulation tissue, excessive suctioning, bleeding from a nearby injury/ surgical site, infection, or the development of a fistula. If the patient has a coagulopathy (such as low platelets or high INR), then this is an even bigger emergency.

What do you do if your patient’s stoma starts hemorrhaging?

• Call for help! Get RT and MD in there STAT!
• Get your PPE on (especially mask and goggles)
• Suction the tracheostomy tube to keep it clear of blood (though be aware, the blood may just keep on coming in severe cases)
• Anticipate a CBC, PT, PTT being drawn. If patient is not already blood typed, anticipate possible massive transfusion protocol (or, drawing a Type and Screen if time allows)
• If patient continues to bleed, anticipate emergent surgery or palliative care in some cases (neck cancers for instance)
• Applying finger pressure in the sternal notch can help stop or slow bleeding coming from deep within the stoma
• Inflating the tracheostomy cuff slowly up to 50 ml air can tamponade bleeding

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Want to review tracheostomy emergencies on the go? Tune in to episode 130 on the Straight A Nursing podcast.