Seizure Management at Night: Nuts and Bolts

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Transcript Seizure Management at Night: Nuts and Bolts

Medical Equipment Problems:
Tracheostomies and Gastrostomies
Nightfloat Curriculum 2010-2011
Lucile Packard Children’s Hospital
Residency Program
Teaching Goals
• Review the critical components of
tracheostomy and gastrostomy tubes
• Begin initial management of tracheostomy
emergencies
• Troubleshoot problems with gastrostomy
tubes
Obturator and Uncuffed Trach
Cuffed Tracheostomy Tube
Bleeding in a Patient with a
Tracheostomy: Differential Diagnosis
Causes
Treatment/Prevention
Bleeding from stoma
Trauma at stoma site
Granuloma at stoma site
Infection at stoma site
Apply pressure, avoid trauma
Triamcinolone, silver nitrate
Antibiotics
Internal bleeding
Trauma from suctioning
Tracheal wall granuloma
Tracheal wall erosion
Tracheal erosion into an artery
Pulmonary hemorrhage
Measure suction catheter; ensure it
does not extend beyond length of
trach tube; suction for 10 sec or less
at a time.
ENT eval, possible excision
ENT eval
Emergent ENT eval
Respiratory/ventilator support
Desaturation in a Patient with
Tracheostomy: Differential Diagnosis
Causes
Obstruction
Mucous plugging
Tube improperly placed
against tracheal wall
Treatment
Suction; replace trach if
needed
Reposition trach
Decannulation
Replace trach
Pneumothorax
Needle decompression
Gastrostomy Tube
Gastrostomy Problems: Tube blockage
• Usually clog as a result of medications
• Treat with:
– Water
– Carbonated beverage
– Pancreatic enzymes
– Replace tube (last resort)
– Change to liquid medications, if possible
Tube Displacement
• Stoma can close within hours if not held open
• Management: Keep site open!!!
– Use a foley catheter
– After new tube is placed, ensure that it is in the
stomach before using
– A false passage may be formed between the
abdominal wall and stomach, leading to
peritonitis. This is especially important in new
gastrostomy tubes less than 4 weeks old.
Drainage around Gastrostomy Tube
• A small amount of drainage is acceptable.
• Keep area dry using nonadherent gauze or
foam; do not use occlusive dressings
• Ensure no cracks in tubing
• Ensure no excessive traction on tube which
can stretch the stoma
• If drainage persists, may need to upsize tube
• In severe cases, may require surgical repair
Redness Around Gastrostomy Site
Causes
Treatment
Granulation tissue
Triamcinolone cream > silver
nitrate > surgical excision
Prevention: avoid traction and
avoid occlusive dressings
Infection
Yeast infection
Cellulitis/necrotizing fasciitis
Irritation from gastric fluid
leakage
Topical vs. systemic antifungals
Systemic antibiotics
Barrier creams; gastric acid
suppression
Tape sensitivity
Avoidance of tape
Gastrostomy Problems: Vomiting
• Causes
– GERD (may worsen after gastrostomy placement)
– Balloon obstructing gastric outlet
– Other medical causes
• Treat underlying cause
Case # 1
• 8-year-old girl with tracheostomy suddenly
desaturates and becomes cyanotic. The first
thing you should do is:
a) Begin chest compressions
b) Administer 100% oxygen by tracheostomy
c) Perform needle decompression
d) Check for tracheostomy tube patency
Case # 1
• 8-year-old girl with tracheostomy suddenly
desaturates and becomes cyanotic. The first
thing you should do is:
a) Begin chest compressions
b) Administer 100% oxygen by tracheostomy
c) Perform needle decompression
d) Check for tracheostomy tube patency
Case #2
• 18-month-old boy post-op day 7 after a Gtube and Nissen fundoplication pulls his tube
out. All of the following should be performed
EXCEPT:
a) Call surgery
b) Place a deflated foley in the stoma
c) Place an NG tube and start pedialyte to
maintain hydration
d) Check new tube placement using a dye study
Case #2
• 18-month-old boy post-op day 7 after a Gtube and Nissen fundoplication pulls his tube
out. All of the following should be performed
EXCEPT:
a) Call surgery
b) Place a deflated foley in the stoma
c) Place an NG tube and start pedialyte to
maintain hydration
d) Check new tube placement using a dye study