Stoma crisis

[trauma1534]

Hello everyone! I've been away from EMT life for a while and thought I would post tonight. I ran an interesting call the other day and thought I would share.

We are called to the nursing home for a patient having difficulty breating. UOA, we found a 62 year old female patient cyanotic, breathing very rapid but shallow. She has a stoma with an O2 mask over it with 15 LPM. Her sats are at that point 62%. Hx: She had just arrived there the night before after leaving a trauma center after being treated for mouth and throat CA. She had a skin graft from her arm to her neck, aprox 1 week prior to discharge to the nursing home. We quickly loaded her onto stretcher and headed on a 25 min. eta to the closest ER. Lung sounds: wheezes and crackles. Pupils are pin point, we notice her rapidly depressing respiritory drive. We continue on to suction the stoma. When we suctioned, her breathing got worse. We preced to place tube into stoma, she stops breathing while tube is in, and when we quickly removed it, she gasped and resumed her respirations. HR is 98, SR. Her B/P is 88/60. Poor skin turger, IV established @ KVO / Normal Saline (since this is all we cary on our trucks). What are you thinking, and what would you do next? There is also a Fentinol patch over her clavicle, and the only new med on her chart is Hydrocodone.

 

[Jon]

From the ALS side, with the decreased respiratory drive and the use of multiple narcotic painkillers, I'd push a little narcan... 0.4 mg in 10cc's SLOW push 1-2 minutes to see if respiratory drive improves... I'd hate to put the patient into pain, but it sounds like they may have OD'd.

I'd also be intrested in looking at the cardiac rythym - perhaps she is in CHF... of course, she's already got O2, and we can't give Nitro, becasue her pressure is already low, and she may already be OD'd on opoids, so no Morphine... so all we can do of "MONA" is ASA. Perhaps CPAP?

 

[Airwaygoddess]

Could have also been a deep mucus plug that was also blocking that stoma

 

[VentMedic]

Recent surgery and probably radiation may have weakened pt's immune system making her a good candidate for PNA and septsis. That could explain some of the wheezes and crackles. She no longer has the nose and upper airways to filter the air before it hits the lungs. If she had been hypoventilating for any length of time, she will have atelectasis. Also nurses are noted for "lavaging" the stomas aggressively when suctioning leading to contaminants introduced into the lungs. Trauma to the carina by repeated suctioning (prior to your arrival) can also lead to infections. The chances for a tracheal/esophageal fistula and false tracking are great on a new stoma. The "tie off" stoma used for throat cancer patients usually heals to be very sturdy. But, due to the extensive incisions needed for the tie off, the trachea can be subject to complications. Inserting a tube can be tricky due to the relatively short distance from the stoma to the carina and the posterior wall incisions. Direct contact with the carina can vagal or suppress respirations just by the pain. In the hospital we will use an adjustable Bivona trach or Murphy tube if absolutely necessary. The tube has to be short enough not to come too close to the carina and still have a large diameter for ventilation. For emergencies on new pts (not known to us and no stoma kit has been customized for them yet), we use a small pedi or infant mask/BVM to maintain ventilation until the proper tube can be obtained. Ventilation in this manner is easier than the usual tracheostomy since there is no communication with the upper airway. If the pt is a full code, a special resuscitation BVM/kit should have been at her bedside. The hospital usually sends it with the pt upon discharge since these stomas require special consideration.

There is also a chance for this pt to have more cancerous tissue that is now in the pulmonary system. Recent surgery and immobility can also make her a candidate for pulmonary emboli. Of course as mentioned by Airwaygoddess, a mucus plug is possible and bronchoscopy may be the safest removal. Foreign body aspiration is also common with these stomas esp. with kids. Since they are usually unprotected and have the negative force straight from the lungs, they can suck in anything loose and close.

There is rarely one cause for a pt like this. The respiratory depression is probably the result of any one or all of the above mentioned possibilites.

 

[DT4EMS]

Outstanding post ventmedic!

I would like to add a couple of things...............

First the respirations were described as "rapid and shallow". That is opposite of what an opiate derivitave would do.

She could have the pinpoint pupils from them, but I wouldn't think that was the single cause of the respiratory distress.

Secondly, when you "suction" a person's stoma their breathing will get worse.

How large was the ET tube you tried to pass into the stoma? Was their an actual need to control the airway with an ET into the stoma or could a child or infant mask work when attached to the bvm? (I am curious not being rude).

The wheezing and crackles is probably the true source of the respiratory distress. So the question....... "Why"?

The low B/P does make you think of LVHF for whatever reason.........

Could be an embolism as well.

Thanks for sharing the call!!

 

[Airwaygoddess]

Vent medic you rock!! another great post

 

[VentMedic]

As mentioned by DT4EMS
Fentanyl and hydrocodone will present pinpoint pupils in their therapeutic levels.

Questions the nurses should immediately be able to tell you;
1. When/if did her mentation first alter
2. Did she spike a temp
3. Did her urinary output decrease
4. Last radiation/chemo tx

This info will give the hospital a quick summary for a direction to start. Of course, a blanket of orders and labs will happen.

Lung field crackles; PNA, atelectasis, kidneys function declining, dialysis may be in close future at least temporarily. Wheezes; accumulating fluids. Probably not a bronchospastic component.

Rapid Shallow breathing;
PNA, increased temp, sepsis, atelectacis, pain, pleural effusions, etc

Suctioning can depress breathing more. Without adequate ventilation/hyperoxygenation method, you can create more atelectasis and hypoxemia, not to mention pain. As the airways collapse, CO2 rises.

Supportive care;
IV; done

Airway;
I would not stick any ETT inside of a new (less than 2 weeks) stoma until a closer examination of the sutures, flaps and carina distance by an ENT doc if possible. Regular tracheostomies that are more than a week old...yes, I would use an ETT if no trach is available.

Two ways to maintain ventilation on a relatively fresh laryngectomy pt;
1. BVM with small mask (infant pedi) The small round infant masks are great for this.
2. Inflate cuff on ETT to max and gently insert the tip of the tube, occluding the stoma from the outside with the cuff.

An emergency laryngectomy kit is best. Nursing homes that accept these pts should always have one. We now keep them in our difficult and unusual airway kit.

There are several systems affected in this pt. One diagnosis will not cover it.
In the hospital this pt would be our "train wreck" for the next few days. In the ER/ICU we would switch to an adjustable trach for long term ventilation once a good look at the stoma is done. She will probably be supported by a ventilator for awhile until each system is buffed up again. Pain management is a must for her while also maintaining her BP. She will undergo direct visualization by bronchoscope to check for plugs, PCP (pneumocytsis carinii) and damage to tracheal wall.

The hospitals I work with have offered education to the EMTs and Medics because of the large number of subacute nursing homes and facilities accepting pts with laryngectomies, tracheostomies, ventilators etc. Unfortunately, the turn out is poor...boring subject because it pertains to the long term and "nursing home" patient many times. I'll throw it in when I teaching BCLS and ACLS.

I could talk about just the laryngectomy and trach pts for weeks (and I do teaching RT students). But, I could get boring too.

Management of the cancer pt is another difficult topic esp. when family panics and calls EMS for a pt who is supposed to be "pallative care" and now they (family) want everything done. The level of pain management these pts are on can be awe striking. And, they are still in pain...

 

[trauma1534]

Very good information you covered here! Thanks. The chances of me having this patient is very great as she is in the nursing home in our call area. This is one of those type patients you don't see enough to keep you memory up on how to successfully treat them. Interesting enough, she did not tolorate the BVM with infant mask over the stoma. She just got worse with each attempt to ventilate. It was a loose loose situation in the truck. We could not get a hold to her airway problem and effectivly treat it. That's why I brought this call to the table here so that I could get other's opinions as to how they would treat this. All the trouble shooting things I have been trained to do on a patient like this, failed. One good thing though... she did not die on my truck... she was still holding on when we got her to the ER.

Update: She was septic... although she did not have any septic red flags per say... she did have an occlusion that could not be removed by suction. The PA explained to me that everytime we would try to suction her, because of where the occlusion was it would stop up her airway... everytime we would try to ventilate, it would move the occlusion the other way and stop her airway up. When the tube was placed, it was against the occlusion, thus giving her no airway. Tough call!! Her tox screen did show large amounts of pain meds... which we did suspect. She is back at the nursing home just standing by for the next time we go and get her and are faced with the same obsticles as before! At least this time, I, along with other members of the squad have been made aware of her case, we had a training meeting on this particular condition. Hopefully this will help give some insite of what to do different next time.

 

[VentMedic]

Sounds like the nursing home needs more education. Every nursing home that takes special airway patients, which there are many different ones, should have an emergency airway kit designed for that patient by the beside.

We make our surgeons draw a picture of the stoma and all of the flaps, sutures etc. More cancerous growths can also be expected.

Good luck

 

[DT4EMS]

Thanks for the follow up! Kudos for the great thread!

 

[Fire219man]

I just learned something from Vent....great post!!!