Patients Name: Samira Patel Patients Age / DOB: 65 year old female on a general ward Major Medical Problem Blocked tracheostomy tube Learning Goal Medical Early recognition of respiratory distress Understanding need for cuff deflation and removal of inner tube Management of tracheostomy emergencies Narrative Description Staffing Case Briefing Manikin preparation Room set up Potential NTS Calling for expert help early Situational awareness Effective communication Planning and anticipation Task allocation Leadership 65 years old woman admitted to ICU following CVA and aspiration pneumonia 30 days ago. Percutaneous tracheostomy inserted in ICU 20 days ago. On long term wean, transferred to HDU 5 days ago and was then transferred to the ward yesterday. Currently on trache mask FiO2 0.35. She is drifting in and out of sleep and on waking seems anxious/confused. Decreased saturations noted overnight and now requiring regular suctioning. You are doubled up with a restless confused patient and see Samira as routine and record her observations 2 hourly. It is mid morning and you are over with another patient in the next bed. The staff nurse is currently with another patient on the other side of the ward, behind the curtains and the NIC has gone off the ward for 10 mins. The FY2-ST4 is writing another patients discharge summary in the office. There is a student nurse observing. PMH: hypercholestrolaemia, DM, HTN, Ex-smoker, No ETHO DH: NKDA, on aspirin, atorvastatin, ramipril, metformin 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 Mrs Patel is a 65 year old woman who was stepped down from HDU yesterday to your ward. She was admitted to ICU following a CVA and has had a tracheostomy in situ for 20 days as she was slow to wean off from the ventilator. The student nurse is concerned Candidates 1X Staff Nurse 1X FY2-ST4 (then a third candidate arrives for help) To Role Players Student Nurse: Can help if told exactly what to do. Able to get other help. about the patient and has called you for help. 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 8, non-fenestrated Tracheostomy tube with inner cannula in situ, with correct ties, cuff inflated & a dressing. On humidified trach mask on 35% 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, bed locker with complete Blue tracheostomy box inc 10 ml syringe for cuff deflation etc- see list inside box Scenario 2 Blocked Tracheostomy page 1 of 7 SaIL Centre June 2014
Simulator operation Props needed Suction unit with Fine bore suction catheters x 5 and gloves at bedside. green Mapleson C waters circuit. Patient unable to make sounds as tracheostomy with cuff up Patient suddenly desaturates to 82%, but improves to 88% if inner cannula is removed and cuff deflated, and improves further if 100% oxygen applied to face and trache. 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, Trach mask and face mask for 02 to be available. Drugs: N.Saline nebs, N.Saline bag, dressing pack Defib, cardiac monitoring, thermometer, BP cuff, obs chart and drug chart, tracheostomy care chart Note to faculty: Underlying cause is an evolving chest infection with high secretion load. The inner cannula has become blocked and when this is removed it causes the tube to be blocked with a dislodge clump of dried secretions. Candidates must follow these steps: re-assure patient, suction first, remove the inner cannula, increase FiO2, call for help, deflate cuff, apply facial oxygen (keeping trach O2 on too) repeat call for help if not arrived The tube needs changing BUT they must not do this without an anaesthetist or Outreach/ tracheostomy expert. They can prepare for the tube change whilst help arrives eg Resus trolley, prepare emergency kit open up tube, test cuff, lubrication, dilators, ties, dressing etc Scenario 2 Blocked Tracheostomy page 2 of 7 SaIL Centre June 2014
Observations: Initial Par score HR 110 1 O2 sats 96% on 35% venture 0 and tache mask BP 95/55 1 Temp 37.9 1 RR 22 0 GCS E=4 V=T M=5 Total Par Score 3 Par score HR 120 2 O2 sats 82% on 35% FiO2 3 BP 105/64 0 Temp 37.8 1 RR 26 2 GCS E=4 V=T M=5 Total Par Score 8 BM 6.4 Crepitations bilaterally. Scenario 2 Blocked Tracheostomy page 3 of 7 SaIL Centre June 2014
Student Nurse Role (Plant) Scenario You ve been handed over that Samira Patel is a 65 years old lady with history of CVA who has stepped down to the ward from HDU yesterday for further respiratory wean and needs 2 hourly obs. She is NG fed, needs assistance with all daily care and has no sitting balance. She has diabetes, hypertension and hypercholestrolaemia. You ve been handed over that her saturation has dropped during the night with increased secretions and appears more drowsy today. She s on FiO2 of 35% oxygen (yesterday on 24%). Mrs Patel suddenly becomes distressed and desaturates further. You call out for help. Underlying diagnosis Blocked tracheostomy Instructions You are a student nurse in your third year, but have never looked after a tracheostomy patient before. You are very keen to learn, and are capable. You can get flustered when things seem to go off plan. Scenario 2 Blocked Tracheostomy page 4 of 7 SaIL Centre June 2014
Patient Role Scenario You are a 65 years old woman who have been admitted to ICU 30 days ago following CVA with aspiration pneumonia. 10 days after admission, a percutaneous tracheostomy was inserted to help wean you off the ventilator. You have recovered from the initial aspiration pneumonia and currently off the antibiotics. You were then transferred to HDU for 5 days period and was stepped down to the ward yesterday for further respiratory wean. You are now on trache mask FiO2 35%. You are unable to move your right side (arm or leg) and unable to sit up or talk. You are not allowed to take anything orally and on NG feeding. You ve started feeling more unwell since yesterday and more sleepy. Today, you don t know where you are and who the people around you are. You have increased cough with increased secretions and requiring regular suctioning. You ve developed decreased oxygen saturations overnight and now requiring 35% compared to 24% yesterday. You suddenly become distressed with retained secretions and start to panic. PMH: hypercholestrolaemia, DM (Diabetes Mellitus), HTN (hypertension) DH: NKDA, on aspirin, simvastatin, ramipril, metformin SH: Ex-smoker, No ETHO. You live with your husband and have no siblings. Underlying diagnosis Blocked tracheotomy Patient Instructions You are becoming distressed with the blocked tracheostomy from the retained secretions and stars panicking and attempt to cough. You are confused and unable to breath. Scenario 2 Blocked Tracheostomy page 5 of 7 SaIL Centre June 2014
Anaesthetic SpR Role Scenario Mrs Samira Patel is a 65 years old lady with history of CVA who has stepped down yesterday from HDU for ongoing respiratory wean and needs 2 hourly obs. She is on NG feeding, needs assistance with all daily care and has no sitting balance. Her oxygen saturation has decreased during the night with increased secretions and appears more drowsy this morning. She s on FiO2 of 35% oxygen (yesterday on 24%). Mrs Patel suddenly becomes distressed and starts to desaturates. You ve been called to help. Underlying diagnosis Blocked 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 ward to see Mrs Patel. Scenario 2 Blocked Tracheostomy page 6 of 7 SaIL Centre June 2014
Blood Results: Name: Samira Patel Age: 65 FBC Hb 102 WCC 14.5 Plt 180 U&E Na 147 K 4.5 Urea 7 Cr 101 CRP 71 ABG Result: Name: Samira Patel Age: 65 ABG ph 7.36 pco 2 6.6 po 2 6.1 on air BE 0.4 HCO 3 24 Hb 100 Na 147 K 4.3 Lactate 2 Scenario 2 Blocked Tracheostomy page 7 of 7 SaIL Centre June 2014