Eric Lawson, MD Profile picture
Aug 16 23 tweets 18 min read
‼️ #CriticalCare #Tweetorial ‼️

🫁 Tracheostomy Basics & Trach Emergencies 🫁

Join me on a review tracheostomy tube basics and can't miss emergency situations!
 
#EmoryNCCTweetorials

#FOAMcc for #CritCare #EmergencyMedicine #HospitalMedicine #MedEd #Neurocrit #PulmCrit

1/🧵
Goals for this #Tweetorial

1-Review basics of the tracheostomy tube
2- Review anatomy relevant to tracheostomy placement
3- Safety tips for your inpatients with trachs
4- Review emergency situations relevant to trachs

2/🧵
Lets start with a case...

60s y/o male with a left basal ganglia ICH 🧠 who is now s/p bedside percutaneous tracheostomy placement 4 days ago. You are called into the room for a high pressure alarm 🚨

What is your first step?

3/🧵
Evaluate the patient!
 
Lets review the head/neck anatomy relevant to tracheostomy tubes!

A percutaneous trach is typically placed between the 1st and 2nd tracheal rings. This image from @derangedphys shows the relevant portions of the trachea

4/🧵
From an internal aspect, the tracheostomy lies below the level of the vocal cords as shown.

Another important anatomical relation to note is the locational of the innominate artery on this image.

5/🧵
Now that you know where the tracheostomy is, what are the components of the tube itself?

1- Outer cannula/Faceplate
2- Pilot balloon
3- Cuff
4- Inner Cannula
5- Obturator

6/🧵
At placement when sizing a trach the proceduralist may consider placing a standard or XLT trach.

Proximal XLT is useful for patients w/thick necks

Distal XLT is useful for patients w/tracheal stenosis

7/🧵
Now that you have a handle on the head/neck anatomy and the components of a tracheostomy tube, what are the other "must haves" in your patient's room?

8/🧵
Patients with a trach in an ICU setting should have the following:

1- Sign on door describing trach
2- Extra trach in the room
3- Obturator/syringe in the room
4- BVM
5- End-Tidal Co2 Monitor
6- Knowledge of where your emergency equipment is! (Airway box, fiberoptic etc)

9/🧵
Back to our case... you have your room prepared, you know your airway anatomy, and the components of the tracheostomy.

So what is causing the ventilator to alarm?


10/🧵
Approaching any trach emergency, prepare backup airway and ventilate the patient as you troubleshoot

3 easy steps (your room has all these materials at bedside!):

1- Deflate the cuff on the trach
2- Bag-Valve Mask ventilate patient via mouth
3- Monitor your EtCO2

11/🧵
Frame Tracheostomy Emergencies in your head based on timing and into 3 main categories:
 
Timing:
Early: <7-14 days
Late: >7-14 days

Categories:
1- Obstruction
2- Decannulation
3- Bleeding

12/🧵
⏳Early Obstruction:
Causes: Mucus plugging, clotting, *always consider decannulation*
Fixes: Pass suction catheter, remove inner canula, direct visualization w/fiberoptic

⌛️Late Obstruction:
Causes: Same as above
Fixes: Same, consider replacing trach at bedside

13/🧵
⏳Early Decannulation:

Causes: Physical manipulation

Fixes: 🛑 CAUTION 🛑 reinsertion is high risk for creating false tract due to immature tract!

-Call for help early, ventilate from above, prepare to intubate
-Trained provider can reinsert w/direct visualization

14/🧵
⌛️Late Decannulation:

Causes: Physical manipulation

Fixes: Ventilate from above, prepare backup airway, reinsert or replace trach with obturator in place

15/🧵
⏳Early Bleeding:

Causes: Typically related to surgical site, frequent suctioning, trauma to external site or trachea, or tracheitis

Fixes: Identify the source of the bleed, if external consider silver nitrite or direct pressure

16/🧵
⌛️Late Bleeding:

Causes: 🛑CAUTION🛑 tracheoinominate fistula is a potential cause and is a surgical emergency!

Fixes: Early help from vascular/IR. Remove trach & intubate from above and hyperinflate cuff. Digital compression through stoma (as shown)

17/🧵
Thats it for a brief overview of tracheostomies and trach emergencies!

Please comment with additional teaching, corrections, or additional comments!

@caseyalbin @drdangayach @Capt_Ammonia @neuro_intensive @JackieKraft4 @EmmGeezee @criticalbeansmd @AvrahamCooperMD

18/🧵
References/Additional Resources:

@nickmmark @OnePagerICU has an exceptional resource on Tracheostomy Emergencies:
static1.squarespace.com/static/5e6d5df…

Excellent review article from UK Guidelines:
…-publications.onlinelibrary.wiley.com/doi/10.1111/j.…


19/🧵
The UK also has an entire society dedicated to trach emergencies:
tracheostomy.org.uk

Review Book chapter on Trach Emergencies:
pubmed.ncbi.nlm.nih.gov/30454773/

TIF Management:
optechtcs.com/article/S1522-…

20/🧵

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Eric Lawson, MD

Eric Lawson, MD Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @EricLawson90

Mar 23
Another #CriticalCare #Tweetorial!

🫀Left Ventricular Assist Device for the non-cardiologist🫀

Join me on a journey through LVADs with some #FOAMcc highlights useful for #CritCare #EmergencyMedicine #HospitalMedicine #Meded

#EmoryNCCTweetorials
@CardioNerds @emoryheart
1/🧵
Goals for this #Tweetorial
1-Review the basics of what an LVAD is and does
2-Discuss indications for an LVAD
3-Review some common complications of the device itself
4-Review systemic complications of an LVAD

2/🧵
Lets start with some basics of the LVAD. Historically the two most commonly encountered are the Heartmate 3 and the Heartware.

We will focus on the Heartmate 3 (Shown below)

3/🧵
Read 23 tweets
Nov 4, 2021
Time for a #CriticalCare #Tweetorial!

‼️Basics of CRRT for the non-nephrologist‼️

Exiting my typical #Neurology wheelhouse as I tackle some #FOAMcc topics for my own learning. Please join in on teaching and address any mistakes!

#EmoryNCCTweetorials
@EmoryNephrology
1/🧵
CRRT- What does it stand for?!

Continuous- Runs around the clock (sort of)
Renal- The beans!
Replacement- More of a rinse than a true replacement
Therapy- It helps!

@criticalbeansmd @EmoryNeuroCrit @caseyalbin @KrafteKraft4 @mallyaa @VijayanMD
2/🧵
Why do we use CRRT instead of HD?

Patient’s with hemodynamic instability (ie blood pressure is so low they can’t tolerate HD)

Conditions where you need to avoid large fluid shifts (like cerebral edema)

3/🧵
Read 21 tweets
Oct 23, 2020
‼️#Tweetorial Time‼️

“Spinal Cord Vascular Supply”

For my pub in @NeurologyCP I reviewed the vasc supply of this small space in the CNS!

cp.neurology.org/content/early/…

@MedTweetorials @RealDrHu @RyanBPetersonMD @Gradydoctor @EmmGeezee @Tracey1milligan @AaronLBerkowitz #MedEd
1/
I relied heavily on @neuroangio1 which has a great in depth break down.

Don’t worry, as their figure shows, this is SUPER easy stuff 🤯.

(This is the experts course)

neuroangio.org/spinal-vascula…
2/
I promised basics though… So lets focus on some vascular spinal cord syndromes. High yield for #MedStudentTwitter and #NeurologyResidents.
3/
Read 13 tweets
Jul 27, 2020
#Tweetorial! Join me on a saga through history and the fields of #Neurology #Neurosurgery and #Pathology! This was prompted by Neuropathology rounds today with @StewartGNeill

"Foix-Alajouanine Syndrome"

@MedTweetorials #MedEd
1/
"Gesundheit" was my first thought when @StewartGNeill said "Foix-Alajouanine" but some reading turned up some interesting facts about this eponym..

2/
Charles Foix was a French internist and neurologist. A student of Pierre Marie (who was an assistant to Jean-Martin Charcot) at Salpêtrière, Foix later taught alongside Georges Guillain.

3/
Read 21 tweets
Jul 15, 2020
#Tweetorial time! A little late this week as I’ve been busy on inpatient. Transitioning to #CommonNeuroConsults and this week will start with a #stroke and #ophthalmology topic @DGlaucomflecken @MedTweetorials #meded #medstudenttwitter

“Transient Monocular Vision Loss”
1/
You may also hear this called “amaurosis fugax” and can be due to an ocular cause, a vascular cause, or an optic nerve head problem!
2/
Let’s start with a brief review of ocular and oculovascular anatomy!

Your optic nerve is cranial nerve 2. This is the nerve that transmits visual information from the retina to the visual cortex.
3/ Image
Read 18 tweets
Jul 6, 2020
#Tweetorial! Continuing with the #NeuroBootCamp my co-chiefs and I are leading @EmoryNeurology on #NeuroEmergencies, today’s #MedEd topic will be:
“Myasthenic Crisis”

Keep in mind I’m approaching this with my #NeuroCritCare hat on @MedTweetorials
1/
Some basic background info: Myasthenia Gravis is an autoimmune disorder causing faulty neuromuscular junction transmission. Typically due to one of the following antibodies:
-AchR
-MuSK
-LRP4
-Can be seronegative

20% have crisis within 1st yr of diagnosis!
2/
Clinically Myasthenia manifests itself with ptosis, fatigable weakness, eye movement abnormalities, and in the case of crisis- respiratory compromise.
3/
Read 20 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us on Twitter!

:(