Tracheostomy Sim Course

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1 Patients Name: Robert Smith Patients Age / DOB: 45 year old gentleman on medical ward Major Medical Problem Displaced tracheostomy tube Learning Goal Medical Early recognition of displaced tracheostomy Understanding the significance of when was the tracheostomy inserted Management of tracheostomy emergencies Proposed NTS Calling for expert help early Situational awareness Effective communication Planning and anticipation Task allocation Leadership Narrative Description 45 years old gentleman with history of severe COPD admitted through A&E 2 weeks ago where he was intubated & ventilated and transferred to ICU with severe Community Acquired Pneumonia. A percutaneous tracheostomy was inserted 5 days ago where he managed to gradually wean off the ventilator and currently is on a trache mask, FiO2 28% for the last 2 days. He was stepped down to the medical ward yesterday for further respiratory wean. However, he still has a secretion load and did not tolerate cuff down attempt this morning. He has otherwise made a good recovery from his infection point of view and currently off antibiotics and his C-reactive protein (CRP) has decreased from 250 on admission to now: 24. He s on a weaning course of prednisolone and continues on salbutamol 6 hourly and atrovent nebs qds. He is NG fed, has poor sitting balance and needs assistance with all daily care and requires two hourly obs. Mr Smith needs to turn to his side to change his sheets. A nursing assistance is helping you. On turning, his tracheostomy becomes displaced. The other nursing staff is on the next bay dealing with a patient and the FY2-ST4 is writing another patients discharge summary in the office. PMH: COPD, Ischemic heart disease (IHD), HTN, Ex-smoker, Occasional ETHO, ET 100 yards DH: NKDA, on salbutamol and atrovent nebs at home, symbicort, phyllocontin, aspirin, atorvastatin, ramipril Staffing Case Briefing Faculty Control Room: 1 x Sim man controls 1 x Sim flyer Faculty Role Players: 1 x Student Nurse 1 x anaesthetic SpR / Outreach team member To All Candidates Mr Smith is a 45 year old gentleman who was stepped down from ICU yesterday to medical ward. He was admitted 2 weeks ago following a CAP and has had a tracheostomy in situ for 5 days as he was slow to wean off from the Candidates 1X Staff Nurse 1X FY2-ST4 (then a third candidate arrives for help) To Role Players Nurse Assistant: Can help if told exactly what to do. Able to get other help. Scenario 3 Displaced tube page 1 of 7 SaIL Centre June 2014

2 Manikin preparation Room set up Simulator operation Props needed ventilator. You ve been handed over that his sheet needs changing. The nurse assistant is available to help you with this. Pt not attached to any monitoring except for pulse oximetry. NG tube in situ. IV access: 24G (pink) cannula. No arterial line. Urinary catheter. Portex suctionaid size 9, non-fenestrated Tracheostomy tube with inner cannula in situ, with loose ties, cuff only partially inflated & a dressing. On humidified trach mask on 28% FiO2. Chest Crackly bilaterally. Need to ensure O2 cylinder is working on arrest trolley for suction if at Guys As per routine ward with bedside trolley, with complete Blue tracheostomy box inc 10 ml syringe for cuff deflation etc- see list inside box) Suction unit with Fine bore suction catheters x 5 and gloves at bedside. green waters circuit. Patient unable to make sounds as tracheostomy with cuff up Patient suddenly desaturates to 82% on turning to one side, but improves to 92% if 100% oxygen administered to face and stoma covered. Fine bore suction catheters x 5, spare trache tube same size and one size smaller, Tracheal dilators spare tapes and dressings. Bag -valve-mask, waters circuit, Resus trolley Drugs: N.Saline nebs, N.Saline bag Defib, cardiac monitoring, thermometer, BP cuff, obs chart and drug chart, tracheostomy care chart Note to faculty: Pt is recovering from a chest infection. The ties have become loose and when he is rolled the tube becomes displaced. (The plant should be on the side to pull tube out.) Candidates must follow these steps: re-assure patient, call for help/ 2222, cover the stoma, apply facial oxygen - or use BVM repeat call for help if not arrived The tube MUST NOT be reinserted, nor a new tube passed through the stoma. As this may cause a false trache and oedema may then block the airway preventing intubation. An Anaesthetist should come and intubate at this stage. The candidates can prepare for the intubation whilst help arrives eg Resus trolley, prepare for intubation- drugs (get a flush- need propofol, suxemthonium. Metraminol (vasopressor) IV fluids for if BP drops), ET tube, test cuff, 10 ml syringe, lubrication, laryngoscope, ties, etc Scenario 3 Displaced tube page 2 of 7 SaIL Centre June 2014

3 Observations: Tracheostomy Sim Course Initial Par score HR 84 0 O2 sats 96% on 28% venture 0 and tache mask BP 122/68 0 Temp RR 22 0 GCS E=4 V=T M=5 Total Par Score 0 BM 8 Crepitations bilaterally. Par score HR O2 sats 82% on 28% FiO2 3 BP 138/75 0 Temp RR 35 3 GCS E=4 V=T M=6 Total Par Score 9 Scenario 3 Displaced tube page 3 of 7 SaIL Centre June 2014

4 Nursing Assistant Role (Plant) Scenario You ve been handed over that Mr Smith is a 45 years old gentleman with history of COPD and was admitted 2 weeks ago with pneumonia. He was stepped down to the ward yesterday for further respiratory wean and needs 2 hourly obs. He s currently requiring 28% FiO2 through trache mask and has been stable except for high secretion load. He is NG fed, needs assistance with all daily care and has no sitting balance. He also has IHD and hypertension. You ve been handed over that his bed sheet requires changing- You will get everything ready and call for help. On turning, you have him turned to you and your at the head end - his tracheostomy suddenly becomes displaced (you pull it out) and you notice this first and inform the nursing staff about this. Mr Smith starts to desaturates quickly to 82%. Underlying diagnosis Displaced tracheostomy Instructions You are a nursing assistant who can do things if you are told exactly what to do and contact anyone if told who and how. Scenario 3 Displaced tube page 4 of 7 SaIL Centre June 2014

5 Patient Role Scenario You are a 45 years old gentleman with history of severe COPD admitted through A&E 2 weeks ago where you were Intubated + Ventilated and transferred to ICU with severe Community Acquired Pneumonia. A percutaneous tracheostomy was inserted 5 days ago where you managed to gradually wean off the ventilator and currently on a trache mask, FiO2 28% for the last 2 days. You were stepped down to medical ward yesterday for further respiratory wean. However, you still have heavy secretion load and did not tolerate cuff down attempt this morning. You have otherwise made a good recovery from infection point of view and currently off antibiotics and CRP has decreased from 250 on admission to now: 24. You re taking a weaning course of prednisolone and continue on salbutamol 6 hourly and atrovent nebs qds. You are NG fed, have poor sitting balance and require assistance with all daily care and require two hourly obs. You need to turn to your side to have the sheets changed. Both nursing assistance and staff nurse are about to turn you, however, on turning, your tracheostomy becomes displaced. The other nursing staff is on the next bay dealing with a patient and the FY2-ST4 is writing another patients discharge summary in the office. PMH: COPD, IHD, HTN, Ex-smoker, Occasional ETHO, ET 100 yards DH: NKDA, on salbutamol and atrovent nebs at home, symbicort, phyllocontin, aspirin, atorvastatin, ramipril Underlying diagnosis Displaced tracheotomy Patient Instructions You are becoming distressed with the displaced tracheostomy and starts panicking. Scenario 3 Displaced tube page 5 of 7 SaIL Centre June 2014

6 Anaesthetic SpR Role Scenario Mr Smith is a 45 years old gentleman with history of severe COPD, on home nebs and ET of 100 years with a PMH of IHD and HTN. He was admitted 2 weeks ago with sever CAP requiring I+V and a tracheostomy was inserted 5 days ago. He is on TM for the past 2 days (FiO2 28%) and has failed cuff down attempt this am with high secretion load. You are informed that his trachoestomy became displaced on turning and with dropped sats to 82%. They require your help urgently. Underlying diagnosis Displaced tracheotomy Instructions You ve just finished a case in emergency theatre when you are called to attend to the ward. You get a telephone hand over. You give the team a telephone advice and then make your way to the medical ward to see Mr Smith. Scenario 3 Displaced tube page 6 of 7 SaIL Centre June 2014

7 Blood Results: Name: Robert Smith Age: 45 FBC Hb 116 WCC 13.5 Plt 210 U&E Na 135 K 5.1 Urea 4.5 Cr 68 CRP 24 ABG Result: Name: Robert Smith Age: 45 ABG ph 7.36 pco po on air BE 0.4 HCO 3 24 Hb 118 Na 136 K 5.0 Lactate 1.8 Scenario 3 Displaced tube page 7 of 7 SaIL Centre June 2014

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