In Situ ED & ITU Simulation - Airway Emergency - Blocked Tracheostomy

Learning Objectives

Learning objectives - Non clinical

• Team leadership and teamworking
• Multi-Specialty collaboration: know who and how to contact help

Learning objectives - Clinical (Medical)

• Awareness of, and able to follow, emergency tracheostomy algorithm
• Re-assessing/repeat steps after a change has been made (eg re-suction after changing inner cannula)

Learning objectives - Clinical (Nursing)

• Know how to suction a tracheostomy and change the inner cannula

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Faculty - Alex Belcher & Ben Atkinson

RCEM Curriculum Coverage Topics (SLOs)

SLO 2 - Support the ED team by answering clinical questions and making safe decisions
SLO 3 - Identify sick adult patients, be able to resuscitate and stabilise and know when it is appropriate to stop
SLO 7 - Deal with complex and challenging situations in the work place

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FICM Curriculum Coverage Topics (HiLLOs)

HiLLO 5 - Doctors specialising in Intensive Care Medicine can identify, resuscitate and stabilise a critically ill patient, as well as undertake their safe intra-hospital or inter-hospital transfer to an appropriately staffed and equipped facility.

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The Case

• Young adult with trache - blocked due to secretions from a CAP
• Background of covid pneumonitis, a long wean and subsequent tracheal stenosis and tracheostomy
• Recent discharge from hospital and developed a CAP with sepsis
• Assessment of a blocked trache and appropriate management
• Transfer to respiratory high care

Use of the National Tracheostomy guideline

• Can be located at https://tracheostomy.org.uk/
• Image below taken from the above website from this link

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Take Home Points

• Turn suction on fully to function properly, and ensure tubing cut so that fits on suction cannister tightly
• Only use soft-tipped suction catheters to suction down a tracheostomy
• Follow the emergency tracheostomy algorithm to cognitively ‘unload’ and ensure no key steps are missed
• Consider using fast bleep for critical care/ENT when airways are critical

Latent Threats identified

• Emergency tracheostomy algorithm not easily available

Some comments from participant feedback from own reflections:

• Not everyone is au fait with traches
• Where to find the guidelines
• Put oxygen on the trache AND face
• There is a recognised UK trache guideline/algorithm
• Do not use a Yankauer suction catheter down a tracheostomy site
• Ensure capnograpy is attached at all times
• Know that only ENT SHO is on site at PHU out of hours (SpR is non resident on call)
• Remember all avenues of support for airway management
• Always clean the inner tube/cannula of the trache
• Call for specialist help early

Suggested improvements from participants:

• Diagram of trache and where blockages could be, hence common sense allows its easy sorting
• All points raised at the time and addressed.
• Location of Glidescope being somewhere other than in a patient bay to facilitate use without disturbing other patient care.
• Make sure all the equipment are in working order (eg the suction) before a new patient arrives (as well as before when you think you may need it)

Faculty Debrief:

• Need to create a checklist to ensure everything prepared for sim, including:
• QR code for feedback/sign in sheet
• Candidate stickers
• Stethoscope charged and ready to go
• Any ipads to be collected alongside the mannequin (depending which one chosen)
• ABG/VBG printed out
• Patient added to oceano

Future sessions:

• Session in September - Trauma