A 37 year old male presents from nursing home via EMS and goes immediately to the trauma bay without stopping at triage. The EMTs tell you that the staff at the nursing home report that he is normally alert and oriented but was found to be “sleepier” than usual. He was tachycardic on morning vitals.
He has a tracheostomy as well as a gastric feeding tube due to a cervical spinal cord injury several years ago that left him quadriplegic. He is chronically on mechanical ventilation. EMS report worsening mental status and hypoxia while en route. They attempted to use a bag valve mask to ventilate him through the trach but it did not help. When you look at the patient he is apparently unconscious and cyanotic. Paperwork confirms FULL CODE.
What are your immediate actions?
Ultimately this patient had an obstructed tracheostomy tube from thick secretions associated with a significant pneumonia. Suction catheter was difficult to pass. The inner cannula was removed and found to be nearly occluded with thick mucus. Additional aggressive flush/suctioning brought up a lot of phlegm/secretions. The SpO2 improved and the inner cannula was replaced with a new tube.
Take Away #1
Rapid assessment of the crashing tracheostomy patient is essential.
ABC-Ts: Airway, Breathing, Circulation, Cannula/Catheter/Cuff
Or if more familiar, consider your DOPES (displacement, obstruction, pneumothorax, equipment, stacked breaths
Take Away #2
Follow the National Tracheostomy Safety Project’s GREEN PROTOCOL algorithm (see below) with escalating maneuvers to attempt oxygenation and ventilation at each step.
Oxygenate mouth and trach
Remove speaking valve/cap
Remove inner tube
Consider passing catheter
Deflate cuff
Remove trach
Standard oral maneuvers or stoma maneuvers
Intubate from above vs replace tracheostomy tube
Take Away #3
If you find yourself needing to replace the tracheostomy tube, consider using an exchange catheter or bougie even if the trach is well established. This provides extra safety. Consider sizing down, especially if changing brands (e.g. Shiley have larger outer diameters than Portex of same inner diameters). Replace with a cuffed tracheostomy tube to aid you in resuscitation even if the original tracheostomy tube was uncuffed.
Ryan N Barnicle, MD, M.Ed is a current third year resident at Stony Brook Emergency Medicine.
References:
Academic Life in Emergency Medicine: Troubleshooting the Crashing Patient with a Tracheostomy (https://www.aliem.com/2018/01/troubleshooting-crashing-patient-tracheostomy/)
Life in the Fast Lane: Respiratory Distress in the Tracheostomy Patient (https://litfl.com/respiratory-distress-in-tracheostomy-patient/)
EM Crit – Management of Tracheostomy and Laryngectomy Emergencies (https://emcrit.org/emcrit/tracheostomy-emergencies/)
Edited by Bassam Zahid, MD