Question

Patient underwent a right radical neck dissection with external carotid artery sacrifice, followed by a right free flap reconstruction, and a tracheostomy.  Overnight, the patient suffered an acute bleed from the surgical wound, causing aspiration and asphyxia.  The patient was coded with compressions performed for approximately 5-7 minutes while patient was in PEA.  A blood clot was seen to be obstructing the tracheostomy………  Answer the following questions--- what would you do next?

1.     What would you do once you saw that a blood clot was obstructing the tracheostomy and the patient’s heart has stopped beating?  This is an emergency situation.  

2.     How was the bleeding controlled?

II.              Patient was stabilized and the patient came out of cardiac and respiratory arrest. The patient was moved to the ICU.  An ABG was obtained while the patient was on 100%, it was ph:7.49/PaCO:225/PaO2:100/HCO3:30/BE:-5/SaO2:97%

3.     What would you do once the patient is in the ICU

4.     Classify and interpret the ABG that is given.  Why do you suppose the ABG like this?  

Answer 1

Ans) 1) Blood clot should be considered as a cause of obstruction especially if blood is seen after coughing or suctioning. Flexible suction catheters are designed to pass via the upper airway, tracheal or tracheostomy tube into the lower airway.

- The tracheal tube is pushed downwards in the trachea to near the carina or beyond. Gentle suction is applied intermittently and the tube cautiously pulled back. The immediate effect of suction will depend on the size and
consistency of blood clot or other secretions. Blood may pass immediately up into the suction catheter and clear the airway as in this case. Alternatively, a large formed clot may be sucked onto the end the tracheal tube in which case the tube and clot are removed simultaneously.

2) Bleeding after tracheostomy is fortunately rare but can happen due to erosion of a vessel or slipping of a ligature. Over-inflation of the cuff is vital to exert pressure on the bleeding vessel and the tracheostomy tube should not be removed as it can cause aspiration and drowning in blood.

3) ICU can be daunting to both the person being admitted and their visitors due to the lines, tubes, wires and monitoring equipment. ICU patients can be connected to a wide range of machines, the most common being a heart monitor and artificial ventilators (when patients can't breathe for themselves).

4)

Arterial blood gases (ABG), a clinical test that involves measurement of the pH of arterial blood and the amount of oxygen and carbon dioxide dissolved in arterial blood, is routinely used in the diagnosis and monitoring of predominantly critically/acutely ill patients being cared for in hospital emergency rooms and intensive care units.

The test allows assessment of two related physiological functions: pulmonary gas exchange and acid-base homeostasis. This is the second of three articles intended to explain the clinical value of ABG to those with little or no experience of the test. The first article focused on the physiological aspects that underpin an understanding of patient ABG results.

The concepts of pH, acid, base and buffer were explained, and the parameters generated during ABG were defined and related to pulmonary gas exchange and acid-base homeostasis.

- The clinical significance of abnormal ABG results, specifically abnormality in three ABG parameters (pH, pCO2(a) and bicarbonate) that determine patient acid-base status.

- Four classes of acid-base disturbance: respiratory acidosis, metabolic acidosis, respiratory alkalosis and metabolic alkalosis. The causes and physiological consequence of each of these disturbances.