Tracheostomy Emergency

This case was written by Drs. Nicole Durfey and Kyle Santee.

Dr. Durfey is an emergency physician at Kent Hospital and a Clinical Assistant Professor of Emergency Medicine at the University of New England College of Osteopathic Medicine.  She has a special interest in simulation and resuscitation and is the Critical Care Director for Kent Hospital’s Emergency Medicine Residency Program.

Dr. Santee is a third year emergency medicine resident at Kent Hospital. He has an interest in critical care medicine, including resuscitation and difficult airway management. 

WHY IT MATTERS

Tracheostomy emergencies are high acuity, low occurrence situations.  Lack of experience with tracheostomy patients can be anxiety provoking for many emergency physicians.  Simulation allows for the practice of an algorithmic approach to the tracheostomy patient with airway compromise.  This case provides both cognitive practice for the identification and treatment of the most common causes of acute decompensation (obstruction and displacement), as well as procedural familiarity with tracheostomy tubes and stoma intubation.

CLINICAL VIGNETTE

EMS called by wife after sudden onset respiratory distress.  Just released from rehab yesterday from severe motor vehicle collision 2 months ago.  Tracheostomy in place.  Sudden onset severe respiratory distress, hypoxic at 80% on a 100% NRB.  ETA 5 minutes. 

CASE SUMMARY

48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress.  The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced.  Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful.  Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure. 

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