Hello

[Bjs04f]

How are things, its been damn quiet on here recently. In the interest of getting us going any any one have an critical thoughts, or ideas on better management of the following.
60yo F trach placed 3 years ago. Pt is vent dependent. 
Call from nursing home: pt has trach bleeding unknown onset. Pt had complained of abdominal pain earlier in the day.
Upon arrival EMS states pt has 1L blood loss from trach, vitals stable
Walk into the room after shooing Tyson away.
Pt has active bleeding around trach from trach site. Inflate the cuff bleeding slows. During this time unable to properly bag, great resistance. Attempt to past ET tube past trach using glidescope, failed, exchanged trach for ETT over bougie. Still unable to bag, lots of resistance, at this point notice face is swelling as is chest, pt decompensates, goes into vfib. Bilateral chest tubes placed with lots of air, acls with multiple shocks, continue to suction and bag with positive capnography, but lots of resistance. Pericardiocentesis negative. Pt goes PEA efforst stopped.
So the questions being, the assumpion was this was a tracheobronchial injury due to subq emphysema. My understanding is step 1 from significant trach bleeding is inflate cff, try to intubate around trach to avoid aspiration. Any other thoughts or things you wouldve considered?

[slevittMD]

It has been quiet on here, which I'm going to try to remedy. I'll admit that I've been part of the problem!

In any case, I wonder if your patient had some type of arterial fistula, tracheoinominate or something similar. They're typically within a few weeks of trach placement, but I wouldn't think they'd have to be. If her cuff was over inflated, could have caused necrosis and a fistula to form. Wherever the blood was from, you're right that if there's significant trach bleeding, the cuff should be inflated and you try to intubate from above.
Given all of the facial swelling and resistance, I'd bet that you were in a false tract, not the trachea, when bagging. I saw that happen once in the ICU with a chronic trach patient who had an issue with a trach, they attempted to replace the trach, but did not put the trach into the trachea, face started blowing up like a balloon, and the patient nearly died due to lack of an airway. The fact that she arrested also makes me think that the trach (and subsequent ET tube throught the trach) were not in the trachea...likely coded due to the hypoxia.

So what to do for her? I think the best option would have been to use a bronchocope to tube her and that way you'd confirm you're in the airway. If you're at UT, you'd have to call anesthesia for this (which probably wouldn't be a bad call no matter where you were), but Lukes and TTH both have bronchoscopes in the ED. I think this woman died from failure to obtain an airway, so anesthesia probably should have been involved when things started to look bad. Maybe a crich would have been an option if you coudln't tube from above? The anatomy is familiar to us and easier than messing with the trach that clearly wasn't working. Not ideal to have two holes in the neck, but I would have tried it if nothing else seemed to be working. Retrograde intubation from the trach site would have been another option. If you were not actually in the trachea, this would have been obvious when the wire wasn't visualized in the pharynx.

[Bjs04f]

so as far as whether we were in trach or not, we indeed were. Bagging through her trach was hard to begin with, used a bougie to go through trach and tube over it. breath sounds present at all times, but she became the michellin man. THoughts were this may have been tracheal necrosis or tracheal disruption as she was so far from trach surgery. Bronchoscope wouldve been great

[pbruss]

yeah i have been off the grid for a while but this sounds like a real shit storm. sometimes no matter what you do you are screwed.

im not a trach expert, but here is my input, i think levit is spot on with the false track. sounds like the trach, for whatever reason, was never in the trachea. this probably caused the bleeding and why bagging got worse, resistance went up, and all the swelling from subQ air after the cuff was inflated. with the trach not inflated there was probably still passive entrance of air into the trachea itself  and that flow was cut off when to cuff was inflated. could also explain why could not pass anything through the thrach because it had no where to go and maybe the cuff was displacing the anatomy thus why nothing could be passed from above.

bronchcospoy would of been very helpfull in this situation if that was the case.

for a nightmare emergent case like this i would recomend starting from scratch. pull out the trach, have someone for a tight seal with take, hand, or whatever, over trach to impede airflow and see if you can bag and or intubate from above.

in general for procedures, if something it not adding up and whats going on just does not make any physiological scene, stop what you are doing and start over in a new location, with a new technique, or with different equipment.

just realized i spelled trach 14 different ways.

[Bjs04f]

bronch would definitiely have been helpful, didnt think of it during the code. It just seemed weird for a trach in place for years to have been in a false lumen