Tracheostomy and Ventilator Education Program Module 11: Emergency Preparedness

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1 Tracheostomy and Ventilator Education Program Module 11: Emergency Preparedness

2 Disclaimer This material is intended for use by trained family members and caregivers of children with tracheostomies who are patients at the Alberta Children s Hospital. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional, so please seek medical advice from an appropriate health professional for questions regarding the care and treatment of any patient. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. 2

3 7/30/2018 Emergency Preparedness A basic introduction to prepare you to deal with emergencies that may occur when a child with a trach tube is at home and in the community Children s Home Care Edmonton Zone 2016, Used with Permission 3

4 7/30/2018 Life with a Trach Tube at Home Activities for your child may require more planning and preparation because of their trach tube or equipment o Activities may have to be modified to prevent any tubing or connectors from getting pulled or putting pressure on any area of your child s skin o Activities may need to be avoided to prevent foreign objects from getting in the airway 4

5 7/30/2018 Life with a Trach Tube at Home Practicing caution with your child and their trach means being careful about the hazards associated: Water, bathing, and swimming Exposure to harsh weather, foreign particles, and outdoor triggers Eating and drinking Types of clothing Play Infections 5

6 7/30/2018 Life with a Trach Tube in the Community Practicing caution with your child and their trach means being aware of the hazards that are associated with living in the community: Having a child with a trach in the community has an associated level of risk where there is a potential for harm, injury, or death because of the trach Learning how to anticipate, plan, and prepare for such events and how to deal with them will help reduce the chances of an emergency occurring and the impacts of an emergency should one occur 6

7 7/30/2018 Trach Tube Changes: PLANNED Your child with a trach will require planned trach tube changes on a regular basis: To prevent gradual mucus build-up inside the tube To meet manufacturer s guidelines To maintain cleanliness With a planned trach change, you will be able to organize your supplies and equipment ahead of time 7

8 Trach Tube Changes: UNPLANNED 7/30/2018 Your child may require an unplanned trach tube change: In an emergency where the tube needs to be changed because it is obstructed and you cannot clear the obstruction In an emergency where the tube needs to be changed because it is dislodged These tube changes are emergency situations that you have practiced and prepared for in advance You will be not be able to organize your supplies and equipment ahead of time this is why your emergency supplies need to be checked regularly and should always be with your child 8

9 7/30/2018 Emergency Equipment FAMILY Emergency Kit (MUST be with your child at all times): Obturator from current tracheostomy tube 2 extra tracheostomy tubes (current size and one size smaller) Trach ties 2 Suction catheters (current size) Sterile Normal Saline syringes for instillation Scissors and Tweezers or Forceps Sterile water soluble lubricant Hand sanitizer and disposable gloves Barrier device Delee suction Refer to Module 9 for other supplies that you may need for your child 9

10 7/30/2018 Emergency Equipment & Supplies FAMILY MUST keep with their child s Emergency Kit: Fully charged suction machine, charger, and suction supplies (including water and cups for rinsing catheters) Trach dressings, cotton tipped applicators, alcohol swabs HMEs as appropriate Trach information, Emergency algorithms (paper copies) Contact information Family, Health Care Team, Emergency We recommend having access to a phone at all times 10

11 7/30/2018 Emergency Equipment & Supplies 11 FAMILY SHOULD also have as supplies at home: Fully charged second suction machine and charger, suction filters, canisters, and tubings IF VENTILATED: FAMILY MUST also have: Ventilator charger, spare circuit, spare connectors, ventilator settings, ROP contact information, and a bagger with mask/connector along with their child s Emergency Kit Second ventilator and charger, spare circuits, spare connectors, humidifier supplies, HME s as supplies at home If your child requires Oxygen, having extra Oxygen supplies as appropriate for your child (tubing, connectors) would be helpful

12 Assessment Knowing your child and their normal respiratory status looks like will help alert you when something is wrong Referring back to Module 4, you should know what the potential signs of respiratory distress are for your child: o Increased work of breathing like nasal flaring, accessory muscle use / retractions, or belly breathing o Changes in colour, respiratory rate, heart rate, cough, breath sounds 12

13 Your BEST Assessment For your BEST day with your trached child, ALWAYS: B: Check your child s breathing E: Check your emergency equipment in case you need it S: Check your suction equipment in case you need it T: Check your child s ties for tightness and safety 13

14 Emergency Complications 7/30/2018 Remembering back to Module 2, the major emergency complications that require immediate interventions are: Airway Obstruction: This can occur because of secretions or a mucous plug, an improperly placed tube, an object, or aspiration of food or fluid Dislodgement: This can occur because of loose or damaged ties, coughing, movement 14

15 Emergency Algorithms 7/30/2018 You have 3 Community Emergency Algorithms to refer to in the case of an emergency with your child s trach: Emergency Obstructed/Blocked Trach Emergency Dislodged Trach Emergency Trach Change All 3 algorithms begin with the following instructions: At any time a child is unresponsive - immediately call 911. Advise 911 that the child has an airway emergency, a tracheostomy tube change is in progress, and your location. Initiate rescue breathing as required. 15

16 Community Emergency Intervention for a Tracheostomy Tube Obstruction/Blockage AHS Calgary Pediatric Home Care Updated January /30/2018 At any time a child is unresponsive - immediately call 911. Advise 911 that the child has an airway emergency, a tracheostomy tube change is in progress, and your location. Initiate rescue breathing as required. Obstructed/ Blocked Tube Assess breathing Responsive? Instill and suction Call 911 Tube clear? Assess breathing Repeat instill and suction Suction longer Go deeper Tube still blocked? Assess breathing Call 911 Change tube* * See Change Tube Algorithm Responsive Call 911 Initiate rescue breathing and if required, CPR Change tube* * See Change Tube Algorithm 16 No Problems Call the Complex Airway Clinic Nurse between 8 am and 4 pm Monday to Friday at Notify Respirologist Problems? Concerns? After Clinic Hours? Call the Alberta Children s Hospital switchboard at and ask for the Respirologist on Call to be paged

17 7/30/2018 Emergency Obstructed/Blocked Trach Obstructed/ Blocked Tube Assess breathing You should know what your child s baseline respiratory effort and colour are If you think you are dealing with an obstructed or blocked tube get help at home if you can and call 911 if your child is not responsive or anytime you feel you need to Instill and suction Responsive? Call 911 Be safe, clean, fast - Clean your hands quickly with hand sanitizer and prepare the necessary equipment and supplies as quickly as you can If your child is breathing and responsive, you can try an instill followed immediately by a suction 17

18 7/30/2018 Emergency Obstructed/Blocked Trach Assess breathing Tube clear? Repeat instill and suction Suction longer Go deeper If your child is still breathing and responsive but you have not cleared the obstruction, you can try a second instill followed immediately by a suction o This time you can suction longer for up to 20 seconds and you can go 0.5 cm deeper than your child s regular suction depth to try and clear the obstruction 18

19 Emergency Obstructed/Blocked Trach 7/30/2018 Call 911 Initiate rescue breathing and if required, CPR Assess breathing Tube still blocked? Change tube* * See Change Tube Algorithm Responsive Call 911 Change tube* * See Change Tube Algorithm You should always be assessing your child if they lose consciousness or stop breathing at any time, call 911 and then start rescue breathing and CPR If your child is still responsive and breathing but you have not cleared the obstruction, change the trach tube following the Tube Change Algorithm 19

20 Community Emergency Intervention for Uncuffed Tracheostomy Tube Dislodgement Partial and Complete AHS Calgary Pediatric Home Care Updated January 2017 At any time a child is unresponsive - immediately call 911. Advise 911 that the child has an airway emergency, a tracheostomy tube change is in progress, and your location. Initiate rescue breathing as required. 7/30/2018 Partial Dislodgement Complete Dislodgement Gently push tube back into position- Use obturator if required Assess breathing Assess breathing Responsive? Responsive? Change tube* *See Tube Change Algorithm Call 911 Assess breathing Call No Problems Call the Complex Airway Clinic Nurse between 8 am and 4 pm Monday to Friday at Notify Respirologist Problems? Concerns? After Clinic Hours? Call the Alberta Children s Hospital switchboard at and ask for the Respirologist on Call to be paged

21 7/30/2018 Emergency Dislodgement - Partial Partial Dislodgement Gently push tube back into position- Use obturator if required Assess breathing Responsive? You should know what your child s baseline respiratory effort and colour are Be safe, clean, fast - Clean your hands quickly with hand sanitizer and prepare the necessary equipment and supplies as quickly as you can If the trach tube is partially dislodged and you can see that the end of the tube is still inside your child s stoma you can gently guide the tube back in place with or without the obturator 21 Assess breathing Call 911

22 7/30/2018 Emergency Dislodgement - Complete 22 Complete Dislodgement Change tube* *See Tube Change Algorithm Assess breathing Responsive? Call 911 You should know what your child s baseline respiratory effort and colour are Be safe, clean, fast - clean your hands quickly with hand sanitizer and prepare the necessary equipment and supplies as quickly as you can You should always be assessing your child if they lose consciousness or stop breathing at any time, you will need to call 911 and start rescue breathing and CPR If the trach tube is fully dislodged and completely out you need to change the tube following your Tube Change algorithm

23 Community Emergency Intervention for Uncuffed Tracheostomy Tube Tube Change AHS Calgary Pediatric Home Care Updated January 2017 At any time a child is unresponsive - immediately call 911. Advise 911 that the child has an airway emergency, a tracheostomy tube change is in progress, and your location. Initiate rescue breathing as required. 7/30/2018 Change Tube Assess breathing Successful? Reposition head and try to insert tube again Successful? Assess breathing Attempt to insert a smaller size tube Successful? Call 911 Assess breathing Call 911 Initiate rescue breathing and, if required, CPR Initiate rescue breathing and, if required, CPR 23 No Problems Call the Complex Airway Clinic Nurse between 8 am and 4 pm Monday to Friday at Notify Respirologist Problems? Concerns? After Clinic Hours? Call the Alberta Children s Hospital switchboard at and ask for the Respirologist on Call to be paged

24 Emergency Trach Tube Change 7/30/2018 Change Tube You should always be assessing your child s respiratory effort and colour Get help at home if you can and call 911 if indicated You need your suction ready to go and a new tube from your emergency kit prepared with the obturator inside and water soluble lubricant on it Get new ties out if you have time Be safe, clean, fast - clean your hands quickly with hand sanitizer and prepare the necessary equipment and supplies as quickly as you can OLD TUBE OUT NEW TUBE IN OBTURATOR OUT ASSESS YOUR CHILD TIES ASSESS YOUR CHILD 24

25 7/30/2018 Emergency Trach Tube Change Assess breathing Successful? Reposition head and try to insert tube again If you can t get the new tube in, reposition your child s head and try again 25

26 7/30/2018 Emergency Trach Tube Change Call 911 Initiate rescue breathing and, if required, CPR Assess breathing Attempt to insert a smaller size tube Successful? Assess breathing Call 911 Initiate rescue breathing and, if required, CPR If you can t get the new tube in after repositioning, get the smaller sized tube and try that one You should always be assessing your child if they lose consciousness or stop breathing at any time, you will need to call 911 and start rescue breathing and CPR 26

27 Emergency Algorithms 7/30/2018 No matter what situation you are dealing with a blocked trach, a dislodged trach, or a trach change - you should always be assessing your child if they lose consciousness or stop breathing at any time, you will need to call 911 and start rescue breathing and CPR Each algorithm is meant to be used to help in an emergency situation and guide you as to what your next steps should be the algorithms should be easily accessible by you and your caregivers to use You can always call 911 at any time 27

28 7/30/2018 Emergency Algorithms Following any of the emergency algorithms will lead you to: o A solution to the emergency you are dealing with + a child who is alert and breathing well and the instructions to: Notify Respirologist No Problems Call the Complex Airway Clinic Nurse between 8 am and 4 pm Monday to Friday at Problems? Concerns? After Clinic Hours? Call the Alberta Children s Hospital switchboard at and ask for the Respirologist on Call to be paged OR o A 911 call and advanced life support to help you with the emergency you are dealing with 28

29 Emergency Algorithms Notify Respirologist: This mean that you have access 24 hours a day to contact a Respirologist either through the Complex Airway Services phone number or through the main ACH Hospital switchboard number you will be able to get clinical guidance and advice You can also contact a Complex Airway Nurse Case Manager or a Respirologist to advise you on illness management as well 29

30 7/30/2018 Trach Tube Changes Any trach tube change for any reason may lead to increased secretions over the next few hours due to irritation of the airway Any trach tube change can also lead to pink tinged secretions after the change because of irritation of the airway by the friction of removing and reinserting the tubes 30

31 7/30/2018 Emergency Planning for Home Work with your health care team to discuss how to create a plan for emergencies in your home that may occur with your child and their trach Organize your child s medical and trach information so you have a record of your child s needs if necessary, including contacts and medications Always check your equipment and supplies at home to ensure that you have an adequate supply 31

32 7/30/2018 Emergency Planning for Home Always check your emergency kit supplies to make sure they are updated and stocked Have a plan for back up power in case the power goes out in your home: o Your health care team will notify your power company because your child is power dependent o Keep a flashlight with fresh batteries near your child at home o Have a plan if the power is going to be out for long periods of time 32

33 7/30/2018 Emergency Planning for Home Have a plan for communication if your phone is not working an extra battery or access to a neighbor s phone Talk to your health care team about planning for transportation in inclement weather and how to prepare for that Check your smoke and carbon monoxide detectors regularly Make an emergency plan with your whole family so everyone knows what to expect in the case of an emergency 33

34 Emergency Suction 7/30/2018 Before you go home, your health care team will help you with getting your respiratory supplies You will apply for both a portable and a stationary suction for home use some families only get one unit If your suction unit fails, you have been given an emergency suction unit for your emergency kit 34 Photo Used with Permission, JD 2017

35 Emergency Suction Photo Used with Permission, JD 2017 If your regular suction unit is not working, you can use this device as an emergency substitute for powered suction It is not as strong as powered suction, but will work in the case of an emergency + one time use only Remove the unit from the package Lubricate the suction catheter in water and measure for your child s depth Put the catheter into your child s trach tube to the correct depth Photo Used with Permission, JD

36 Emergency Suction 7/30/2018 Put the mouthpiece attachment into your mouth and suck in like a straw while holding the mucus trap attachment upright You will see secretions fill into the mucus trap Stop suctioning after 5 seconds like normal suctioning You can repeat this again if needed This suction unit will hold about 20 cc s of fluid, so you will have to empty it once you have suctioned and rinsed distilled water through the unit if you need to continue suctioning If you have to use your emergency suction unit, talk to your case manager about getting a replacement for your emergency kit 36

37 Barrier Device 7/30/2018 If you have followed the tube change algorithm and are unable to get a tube back into the stoma: Make sure 911 is on the way to help you You may have to start rescue breathing/cpr as per your algorithm if the child is unresponsive, not breathing, pulseless You can use a barrier device to give your child rescue breaths to prevent direct contact with exhaled air or discharge from the stoma Photo Used with Permission, JD

38 Barrier Device You can use it for mouth to mouth rescue breathing ONLY if your child can breath through their mouth and nose If you need to use it to deliver rescue breaths to the stoma, you will have to modify it to fit over the stoma using the following steps: o Avoid touching the filter to prevent contamination o Open the package and remove the barrier device o Unfold the barrier device and use the scissors from the emergency kit to trim the excess plastic around the white filter until it looks like: 38 Photo Used with Permission, JD 2017

39 Barrier Device Place the filter directly over the stoma and secure with your hands Make an airtight seal with your lips over the barrier and the stoma Gently and slowly blow air into the stoma watching for chest rise - you only need to provide a slow, small amount of air into the child s chest to inflate their lungs Provide 1 breath every 3 to 5 seconds or about breaths per minute Your rescue breaths are successful if you see the chest rise and fall, and you hear and feel air escape from the stoma 39 Photo Used with Permission, JD 2017