obturator placed in trach stoma?

[SunnyAndrsn]

One of my co-workers told me she was told not to replace a trach if a pt. de-cannulates herself. Instead, we are to call 911, and in the meantime, she said, "we are supposed to place "this" (she showed me an obturator in a plastic bag) into her stoma."

HUH???? I told her that didn't seem right to me, but she said "well, management says we need to protect the airway"

I don't understand how placing an obturator into a stoma will protect it. Am I being obtuse or are my managers way off here?

At my part time job, I do homecare for a trach pt. and had to go through additional training to work with him. Never, ever we were taught to do this, it was always an emergency trach change--period.

[SunnyAndrsn]

Unless it was a new trach with the obturator in place? I simply cannot see placing an obturator without taking any steps to secure any type of airway. Additionally, there is a chance that the EMT or PM will not be able to manage the trach.

Nope, it was just the obturator, period. I talked to management about this today. Right now she's not with us, she was sent to a psych unit.

I was taught that if a pt. decannulates, always, always, always 1. have O2 available, 2, have the same size trach and one size down to re-insert ASAP. If for some reason, the current trach size can't be re-inserted, then have a size down to try.

So all of this crap with the obturator did NOT make sense to me. This is not even a critical thinking issue, this is just plain use your brain.

[SunnyAndrsn]

If you were to stick the obturator in the airway until EMS arrived, your patient would be dead.

Occluding the airway like that would be equivalent to throwing a plastic bag over your head until help arrived.

Yup, I agree...I had a chat with managers about this today. Small but dim lights appear to be coming on. We don't deal with trachs very often, and thus a lot of confusion. But what do I know, I'm just a bedside nurse, and a fairly new nurse as well. Never mind that I've been working with trachs at my PT job since Feb. Lots and lots of trachs...additional training, lots of training to work with peds pts...but management doesn't like to listen.

[BBFRN, BSN, PhD]

Greaaaat- psych + traches= a dream combo there. Not. Glad you brought up the misinformation before they killed somebody.

[lilta]

Actually. Your manager is right!!

you place the obturator to avoid closure of the stoma and maintain that airway, bag the patient, and call 911. Respiratory staff or an anesthesiologist will reinsert the trach . If you place the tracheostomy tube wrong (which is not uncommon) you may create a false passage which leads to obstruction and pneumothorax. This happens because you placed it in the pretracheal area. remember, if the tube falls out within 48 hours of insertion ,the track is noy formed yet, reinserting will be a big mistake. Orotracheal intubation is advised if you can. I love this web site but please DO check the literature when questioning the protocols. this is all over the medical websites.

[AprilRNurse]

Old thread.... dead conversation.

However- they are all correct. You should replace the trach. Why leave someone without a patent airway if you can help it? I worked homehealth- we were taught to always replace the trach asap. We were to always have a spare trach with us- both in the same size, and in 1 size smaller in case of decannulation.

[nursel56]

Actually. Your manager is right!!

you place the obturator to avoid closure of the stoma and maintain that airway, bag the patient, and call 911. Respiratory staff or an anesthesiologist will reinsert the trach . If you place the tracheostomy tube wrong (which is not uncommon) you may create a false passage which leads to obstruction and pneumothorax. This happens because you placed it in the pretracheal area. remember, if the tube falls out within 48 hours of insertion ,the track is noy formed yet, reinserting will be a big mistake. Orotracheal intubation is advised if you can. I love this web site but please DO check the literature when questioning the protocols. this is all over the medical websites.

We're discussing care of patients in sub-acute areas and in home care. There is no respiratory or anesthesiologist to call to reinsert the trach. NrsKaren explains it very clearly in her post, and the links she posted are a comprehensive overview of this issue.

[NeoPediRN]

Never ever EVER. If a trach comes out and the patient has severe enough stenosis that there is concern it won't be able to go back in, then they have 2.5 ET tube at their bedside that the MD will try to intubate with until they can get to an OR. Otherwise, if a trach comes out and the stoma starts closing, it's bag valve mask and to the ER they go.

[NeoPediRN]

BTW, all of our nursing staff is trained to replace the trach. I have replaced many, both routine and emergent. The more you do it the more comfortable you become.

[NeoPediRN]

I got a puzzled look and was told that the last time she decannulated, she was sent down the street to the hospital and this is what they sent back to manage the airway.

I asked her if it was possible they sent the obturator so that we, at our facility, could re-insert the trach itself, since the nurse who sent her in didn't have a clue how to re-insert the trach? It appeared that small (but dim) light bulb came on over this manager's head. She said she would bring it up at the morning meeting (management meeting)...

I just don't know why the heck we are taking pts. that 1/2 the nurses and none of the managers know how to care for.

Your facility sounds incredibly dangerous. Trachs aren't something you can just accept lightly. Most patients have suction/CPT parameters, and a lot of work goes into maintaining them and preventing tracheitis and PNA. These patients also generally need closer monitoring because of the risk of plugging...hard to make happen when you have a high patient ratio. If your MANAGER has no clue how to manage these patients but is willing to toss them to you without taking the time to have respiratory properly educate staff, it really casts a poor light on your unit as a whole! You generally don't need the obturator to replace a trach, but you'll occasionally have a custom or flimsy trach that won't go in without it. Not ideal for an emergency trach change or replacement, but it can happen.