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How do I protect airway when trach gets pulled out?

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by ahicks ahicks (New) New

I am a new grad working in the ICU. Recently there was a patient in my ICU that pulled out their own trach. What is the best way for me as the nurse to protect the airway until the doc can get their to put trach back in. Please elaborate, I have very little experience with trachs.

getoverit, BSN, RN, EMT-P

Specializes in ER/ICU/Flight. Has 18 years experience.

The best way to protect their airway is to reinsert the Shiley and you don't need a doctor to do it. If you're unfamiliar with this, no big deal...I'm sure anyone of your co-workers or RTs could help you learn how.

Of course you should have sterile gloves, suction kits, French caths, BVM, etc in the room for every patient with any kind of airway adjunct.

Agreed....anyone taking care of a trach pt needs to be able to emergently reinsert the airway.

Place the obturator back in the trach and insert at 90 deg, then turn. Get the RTs to show you.

All trach pts should have the equipment near the bedside- traditionally taped to the wall above the bed.

You need to insert a new trach (which should be at the bedside....one the same size and one the next size down) or the obturator. If you cannot place a new trach or obturator the next best thing is to take an ETT and place so that you can ventilate the patient until you get an appropriate clinician to the bedside.

RescueNinja

Specializes in ICU, ER. Has 1 years experience.

Ditto what everyone else said. It is your responsibility as the pt's nurse to ensure all emergency equipment is in the room (this includes back-ups for trachs).

Thanks for all the replies. I guess I was under the impression that only a doc could reinsert the trach. I will be sure to check my hospital policy as well.

RescueNinja

Specializes in ICU, ER. Has 1 years experience.

Thanks for all the replies. I guess I was under the impression that only a doc could reinsert the trach. I will be sure to check my hospital policy as well.

Good luck! Some hospitals train their nurses to reinsert in an emergency situation and others just expect you to know it.

XingtheBBB, BSN, RN

Specializes in OR, peds, PALS, ICU, camp, school. Has 20 years experience.

We don't have a policy for keeping the next size down at the bedside but I always toss one in the room when it's my pt. Also, if you can't even get that in... stoma closing too quickly or too much... put in a suction cath. You can mechanically ventilate through that to a point. (resp will help you get it connected up with a 5 ETT) At least you're holding it open until the MD can dilate.

tri-rn

Specializes in MICU/SICU.

So which should you put in ... the new trach or the obturator? And how do you mechanically ventilate if you opt for the obturator?

XingtheBBB, BSN, RN

Specializes in OR, peds, PALS, ICU, camp, school. Has 20 years experience.

You might need the obturator to place the new trach. Some would place just the obturator in a true "can't re-cannulate" emergency just to hold the place. If the smallest trach on the floor doesn't work, I'd opt for the suction catheter over the obturator. That's just me in my experience. Ask around work to see what they prefer. Remember, most likely, your pt can be vented with a face mask, too, if you loose your stoma. Know the history to know when they can't.

All trach patients should have emergency trach supplies at bedside. That being said, I had a patient the other night who had been there for 2 days and nobody bothered to place the emergency supplies at the bedside or or routine trach care supplies. When I asked the patient if she had been getting routine trach care, she told me "not so far". I couldn't believe that had happened in our ICU!

We dont stock trach care supplies on the floor, and we can't obtain these supplies in the middle of the night. So, I did what I could with what I had. The patient was "supposed" to go home the next day, so I ordered one trach care kit for the next day. I'm glad nothing happened on my shift!

RN Joe 86

Specializes in CCRN, MICU, CCU. Has 10 years experience.

Great question! Hopefully there is an obturator in the room. If not, most trach stoma sites are well developed anough that with a little surgilube you can place it back in. If all else fails and the RT or whoever isn't there to help, occlude the trach site and either place them on a nrb mask (If they're not apneic) or bvm them until help arrives.

I work in a NICU and we always have a trach "ready to go bag" at the bedside, it is also brought with us if we are taking a field trip with the pt. In the bag is a trach of same size and one size down, suction catheters, sterile gloves, anything we would need should a trach come out or if we needed to emergently change it, and it is the nurses responsibility to care for the trachs, including the once a week trach changes where we take the old one out and put a new one in

CNL2B

Specializes in multispecialty ICU, SICU including CV. Has 10 years experience.

Ditto what everyone else said. It is your responsibility as the pt's nurse to ensure all emergency equipment is in the room (this includes back-ups for trachs).

I'm not sure about the "ditto" part - at my hospital, it is not the nurses responsibility to reinsert. Yes, we need to ensure all the appropriate equipment is in the room (extra trachs, obturators, etc.) and know who to call, but that's it. I do work at a teaching hospital and our docs are in a call room on the same floor of the hospital though -- at most, a few minutes away. Typically what we will do is just manage the airway until they get there. Usually you can get by with bagging a patient for a little while (may need to cover the stoma) if they need it. What I have usually found is that the ones that are pulling out their trachs are usually feisty enough to breathe on their own for a few minutes -- LOL! (although that certainly isn't always the case!)

ShaunES

Specializes in ICU. Has 1 years experience.

In our hospitals ICU it is policy that nurses do not reinsert airways (how often do you actually get to use it, and do you want to stuff it up and make further reinsertion more difficult?), nor do we keep trachys at the bedside (a lot of waste given all items at the bedspace are the patients, and when they leave it all gets chucked/taken with them).

The intubation trolley has all the equipment needed, and the difficult airway cart has even more in the event it all goes pear shaped.

These are ~15 seconds from every bed, and we have two medical staff covering every 8 beds, for a total of 8 medical staff, and a minimum of two senior registrars.

I'm not sure all these instructions of "put it back in" is wise, given that every situation is different (surgical trachy vs perc, why are they trachied, etc)