SOB trach pt scenario

[ericenglund]

med list

allergies

Respiratory rate/quality

last time the facility checked his BS and what the results were(if you can get them to dig up the paperwork)

did they give him insulin or if the results were high?

BP

[SWM_Medic]

Need to get an IV established NS TKO for now. How did the sputum look when he was suctioned last? Any complications with the surgery?

[Doczilla]

Stop screwing around with the history. Suction aggressively, with a squirt of saline into the trach if needed, and if he doesn't get instantly better, replace the trach with a new tube now. This is your first and only priority right now. Get the full history afterwards or broaden your differential diagnosis after you have done this.

'zilla

[tniuqs]

Just a stupid question, whats an ALF just to be certian I suspect are you infering Amyotrophic Lateral Sclerosis, therefore death from Respiratory Failure is the most likely senario just based on my presumtion, its an insideous, nasty diease process and those with the dx of this, typically have 3 to 5 years left of continuing degeneration. I would hazard a leap of faith that this patient's post -op complication for a trach was failure to wean or chronic aspitation pnemonias resulting from loss of swallow control.

Secondly, an no intent to bust chops but Shannon an very open ended senario is very open to tons of conjecture and (just my 2 cents) presentation in a teaching senario is huge but please just for me just include a tad more info than what you have initally started .. again I think serarios are a blast but we are shooting in the dark right now well accept for blood sugars off the richter scale and recent onset of polydipsia, or is this the diffinitive dx in.

I suspect this patient has urinary cath in situ, so ins and OUTs are a huge diagnostic feature as well, no mention in the onset of PMHx or Meds or type of trach ? cuffed ? non cuffed, was patient ventilated and on what mode ? or just a hi flow "T" piece or humidivent ?

My rational in asking these questions is that very unlikely on most Ambulances (if the patient is breathing without ventilatory assistance) that a trach cradle is available to administer higher levels of O2 OR a even if 'T" piece is compatable with on board kit.

So lets assume that we have placed this possibly "Hyper Glycemic" patient on a BVM, so what am I feeling when I assist with ventilation, are we observing Kussmaul type respiratory pattern ... that would be my guess ?

I guess I am saying that Paramedics and EMTs should be painting a thoughout picture, the hands/eyes/ and toys of the ER MD! If I were an MD recieving an info patch or questions in how to treat ... hope your getting my point, it is intended as constructive critasism only.

Ok so an IV is established, so where do we go from here ?

cheers

[tniuqs]

Stop screwing around with the history. Suction aggressively, with a squirt of saline into the trach if needed, and if he doesn't get instantly better, replace the trach with a new tube now. This is your first and only priority right now. Get the full history afterwards or broaden your differential diagnosis after you have done this.

'zilla

Hold yer HORSES there doc !

Ok AIRWAY FIRST but Are you suggesting go way beyond scope of practice and re cannulate with a Trach? (good grief man) even if this is an ALS provider in EMS, that they should pull a trach (a fresh one at that ???) My docs in the ICU would kill me slowly or hand me over to ENT for a nice Lynching, a cooks stylet may save yer bacon.

Ok I would personally pull the Tube as a Paramedic/RRT IF it was not patent but I would stand a huge chance of getting my "you know what" slapped by my Medical Director, if I did not just use an ETT.

Again my point in this senario, it is NOT clear if the patient is frank respiratory comprimise other than sats low .... again my pet peive is the machine really working ? The last post by shannon was lung sounds CLEAR and RR = 20, upper body pink, lower body blue but this tachycardia of 160 is a bit disconcerting , You Think ?

[JPINFV]

Well, to be fair, are we talking about replacing the entire trach or just the inner lumen?

[Doczilla]

ALF is an assisted living facility.

If the trach is not fresh (i.e., <1 week old) the you absolutely should pull the tube and replace it with a new one if the patient does not respond to aggressive suctioning. This patient is not in the immediate post-op period, and therefore changing the trach tube does not pose the same hazards as doing it in the ICU the day after the surgery was done.

The important thing here is that any trach patient in distress should be immediately removed from vent (if on one), suctioned aggressively, and bagged. If they don't turn right around, replace the tube. If you don't know how to work a trach tube, then you can use an appropriately sized ET tube through the tracheostomy hole. This patient has a pulse ox of 70%, tachycardia and tachypnea. He is critically ill at this point. The more you fiddle-fart around doing things like IVs that won't really help, the worse the patient will get.

Replacement of a tracheostomy tube is well within the scope of practice for a paramedic. If you are a BLS provider, then ask the nurse to do it. It is part of their routine training for care of these patients and well within their scope of practice to perform, even without a direct physician order.

If you replace the tube, and he still doesn't turn around, then you can explore everything else. Several good ideas along this line such as sepsis, pulmonary embolism, and dysrhythmia have already been mentioned.

'zilla

[Dustdevil]

If you replace the tube, and he still doesn't turn around, then you can explore everything else.

If you think about it, this is really a no-brainer. It is akin to repositioning your patient's head before assuming he has an obstructed airway during CPR. You don't just jump right to abdominal thrusts without first addressing the easy and the obvious.

Horses before Zebras.

[VentMedic]

If you remove the inner cannula and it is clean, I would not advise pulling a trach.

If you hear breath sounds and good air movement, don't pull the trach.

If you feel air movement through the trach and a suction catheter can be passed I would advise not removing the trach.

Put the inner cannular in or briefly insert the obturator to dislodge plugs if necessary. This ensures trach patency.

If it is a fenestrated trach and you want to bag the patient, put the inner cannula back in.

Make sure the trach is not a custom and if it is, WHY?

Ask to see the standby trach to help identify it.

If the patient is not moving air through the trach but a suction catheter passes the length of the trach before meeting resistance AND the patient can still speak without a speaking valve (PMV), the trach is false tracked. If you remove it you still may not be able to pass it through the correct path. Support with oxygen from the upper airway and occlude the stoma if the patient is still moving good air through the upper airways.

Ask nurse when and WHO replaced the last trach. Even in places with RTs and qualified RNs, an ENT may replace some trach due to special problems such as tumors or coag problems.

Some hospitals do not change the trach at 7 days post op but may elect to do it at 30 days at the ALF, SNF or whatever. That first trach change can be very difficult even at and especially at 30 days.

Reposition the patient.

Unless the patient has a "tie off" as in a laryngectomy or some upper strictures, he/she can still be intubated orally if the unable to put the trach in correctly OR if you have NEVER put a trach in. DO ONLY what you know and use the equipment that YOU are familiar with. If you create a fistula the patient will require extensive surgery and will probably be FUBAR.

Ask for an inservice on trachs that are in your area. Different hospitals and subacutes usually use their favorite brand unless it is a special case. Learn to identify and assess a trach before just pulling. Some "trach looking" devices must be inserted under fluoro and have "dry wall" type flanges that anchor it. Those make a big mess if you pull them out. There are 300 different airway devices that can be found in NH, Subacutes and ALFs. Not every piece of plastic in the throat is really a run of the mill "trach".

We have offered dozens of these inservices at the ALS stations. Unfortunately, attendance is low because it is a "nursing home" associated thing. Also, because they believe since it is in their scope, there's nothing to it. And, when people tell them there's nothing to it, they never seek any further training or education. They assume any tube in the throat is a "trach".

This is my soapbox today because I now have a 35 y/o man on ventilator running ARDSnet protocol following a Paramedic pulling and reinserting the trach ripping trachea at a SNF. The guy probably won't make it. The guy was still talking with his PMV valve when the trach was pulled. The patency of the trach was never checked. Reason for SOB? Spiked a temp with the onset of PNA.

I've been working as a Paramedic and RRT for 30 years and there are still some trachs I will not touch without all of my hospital gadgets and the number of my favorite ENT doc nearby. It helps to know the anatomy, disease process and have a plans B, C and D. LMAs are also nice to have around as well as a baby BVM mask.

[tniuqs]

ALF is an assisted living facility.

One can now clearly see that many and most abbreviations are not clearly defined, cross borders, called LTC here.

If the trach is not fresh (i.e., <1 week old) the you absolutely should pull the tube and replace it with a new one if the patient does not respond to aggressive suctioning. This patient is not in the immediate post-op period, and therefore changing the trach tube does not pose the same hazards as doing it in the ICU the day after the surgery was done.

In my Hood, well unless one has a couple of registrys, a Paramedic would be practicing beyond scope, if this trach exchange was performed. I have done many of these in fact I suspect more than most MD (even those practicing in ICUs) honestly speaking from experiance you can be in a world of hurt if one is not experianced, pneumo medistinum comes to mind immediately, most inexperianced providers will forcefully ventilate resulting in ... well immediate disaster. My humble advice would be ... well if this was the senario to visualise the cords, pass the ETT, then deflate the trach cuff, remove it, then advance the ETT. Just the reverse procedure if on is doing an elective Surgical Tracheostomy in a controlled enviroment. The type of TRACH or manufacture is really signifigant query here, as most as in fresh trachs the Portex cuffed unfenstrated is used to decrease possible infection complications, later on Shileys are used, fenstrated, cuffed with replaceable inner cannula, not only for easy of cleaning but for improved weaning outcomes.

The important thing here is that any trach patient in distress should be immediately removed from vent (if on one), suctioned aggressively, and bagged. If they don't turn right around, replace the tube. If you don't know how to work a trach tube, then you can use an appropriately sized ET tube through the tracheostomy hole. This patient has a pulse ox of 70%, tachycardia and tachypnea. He is critically ill at this point. The more you fiddle-fart around doing things like IVs that won't really help, the worse the patient will get.

Off the vent, agreed, suction yes, but ETT via tracheostomy unless it is 2 sizes to small, one is begging for more problems ETTs are not rigid enough, and leave the stoma for an expert like ENT, (or a senior RRT) ps that's Ear/Nose/Throat and Wallet, sorry inside joke.

Replacement of a tracheostomy tube is well within the scope of practice for a paramedic. If you are a BLS provider, then ask the nurse to do it. It is part of their routine training for care of these patients and well within their scope of practice to perform, even without a direct physician order.

Doczilla are you advocating on an international forum that one should follow your rather aggressive suggestion ? hmmm ?

Ok like a real RN? in a long term care facility? Man, ones lucky if you have an LPN on duty, besides most RN's here would cower, besides in this e-senario if you had an RN worth her/his salt there would be no dispatch, thats why they called EMS in the first dang place and not a logical thought process.

If you replace the tube, and he still doesn't turn around, then you can explore everything else. Several good ideas along this line such as sepsis, pulmonary embolism, and dysrhythmia have already been mentioned.

If the patient is still living ?

Yuppers first look at the screen first for SVT .... hypotension from a reversable cause or maybe just order a serum cortisol, hey it "could" be addisons crisis too, but then hypoglycemia as opposed to hyperglycemia could be a dif dx. Can an REMT-P do CBC or Ca/vO2 or even bedside troponin ? meh get the going to ER I say Paramedics in this senario are way over their heads.

Do you see why I am countering with these points , we are all shooting in the dark with this senario, simple.

cheers happy fishing.

edited for atrocous spelling errors