Airway Question

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The following is a real call I ran a few months ago. Feedback and suggestions would be nice. I want to know what more I could have done. Here goes, 60 something male with clogged trach and hx of throat cancer among other things. I get on scene and pt is in cardiac arrest. I work the arrest, blaw blaw blaw. Open airway and attempt to bag pt, and hear air coming out of tracheal stoma without chest rise and fall. Then I bag stoma without compliance. Then attempt to suction stoma with whistle-tip catheter and nothing. Then I attempt to suction with Yankauer and get nothing. Bag again and nothing. Then I intubate stoma and get no rise/fall of chest and no compliance with BVM. Then I try and intubate with no land marks due to throat cancer surgery but do get into trachea and have no rise and fall and bad compliance. Now he has gone from PEA to flatline. Still working the arrest, I try combitube and more suctioning in route to hospital. Combi goes in trach (what are the chances) and again have no compliance. pt is pronounced at hospital. Ever heard of surgical airway below tracheotomy? Was there anything else I could have done?
 
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Interesting, was the stoma trach trochar device remained in the patient or did you remove it ? As well, one should never suction an stoma with a Yankauer, it is too hard and rigid and can cause major soft tissue damage. Alas, if that is all you got.. though, a suction cath such a a 8 0r 10 french can be used, since it is mainly secretions.

I would had intubated through the stoma, then you know you are past the opening. The combitube, should had worked (congrats getting the trach.) since it lies just anterior of the carina junction.

Sounds like it was meant to be... nothing more than some terminal or outstanding medical problems.

R/r 911
 
Upon arrival, I didn't see any tracheal tube or trocar device. All I saw was a hole. I did learn my lesson regarding the use of a yankauer as it did cause some bleeding but I probably would do the same thing again considering it was a last resort situation. Also, the pt had a very strange airway because when I inserted the ETT into the trachea, it felt soft instead of rigid as a trachea should be, like it had been surgically removed but I don't know that for sure.

This case has bothered me for several reasons. By all accounts, this pt was fighting his cancer and did not want to die. This pt was in his early 60s, so he was still fairly young and judging by his slow heart death and by what I was told, I am quite sure the pt did die of apnea due to tracheal obstruction. Therefore, it pains me that I couldn't have done more........but oh well.........
 
That sucks.. but, it sounds like he was a train wreck with the outstanding conditions. Actually, with the extent of previous involvement, there is not much that probably could ever be done. In the outlook this type of disease is very painful and long enduring... he might be in peace.

R/r 911
 
I agree, not much that could have been done. The only other alternative is to remove the trach and attempt another surgical airway...........
 
Do you know what caused the airway obstruction? I think that is the critical question regarding your patient. What did you get when you suctioned out the trach? Intubating through the stoma was a good idea.
 
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