#24 Rapid Responses

Jami Fregeau, RN walks through rapid responses that nurses can (for the most part) manage independently. Hold on to your seat as we discuss equipment malfunctions and how to be prepared for when it happens to your patient.

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Trach Emergencies

If your patient has a tracheostomy, you should always have the following at the bedside:

  1. Trach tube of the same size and one smaller
  2. Lubricant
  3. Obturator (blunts insertion to prevent damage to soft tissue)
  4. Trach ties
  5. Ambu bag
  6. 10cc syringe
  7. Suction setup with Yankaur and flexible 14 Fr suction catheters
Academic Life in Emergency Medicine (ALiEM)

Decannulation: What do you do if the trach comes out?

Re-cannulation Steps

  1. Oxygenate with by mouth unless obstructed, otherwise use pedi BVM or LMA to create a seal and bag stoma
  2. Insert suction catheter: Can it pass? 
    1. YES: Suction.
    2. NO: Dislodged or obstructed
  3. Flatten patient with hyperextended neck
  4. Insert with obturator
  5. Remove obturator and insert inner cannula

Important to keep in mind

  • Partial removal can obstruct airway
  • Do attempt re-cannulation if trach is fresh (<7 days old), concern for placing false passage into cutaneous hole which can cause severe subcutaneous emphysema 
  • Oxygenate with BVM over mouth while occluding trach site or at trach site
  • Cannot bag without a cuff (will know if there is a pilot balloon)

Chest Tube Emergencies

What should be at the bedside?

  • Kelly clamp x2 (to assess for air leak location)
  • Vaseline gauze
  • Sterile gauze
  • Tape (silicon, or any kind that will make a good seal)
  • Bottle of sterile water or extra suction chamber

Steps for air leaks

  • Determine location of leak
  • If internal, know that this leads to subcutaneous emphysema, then tension pneumo, then cardiac tamponade

Steps after accidental removal

  1. Valsalva maneuver (bear down) to remove air from the pleural space
  2. Apply vaseline gauze, then sterile gauze, then occlusive dressing
  3. Call team for possible replacement

If dislodged at connection to collection chamber

  • Clamp, put tube in water, or cover seal with your finger
  • Reconnect to new collection chamber

Accidental G-Tube Removal

  • Replace with foley of the same size ASAP to keep track open
  • Potentially high morbidity when the stoma tract is immature. Call team before attempting to insert foley if it is a fresh stoma.
YouTube: Feeding Tube Replacement