Pediatric emergency medicine trisk 4645 4645
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might indicate an intratracheal granuloma, which should be evaluated by direct
visualization, typically performed by an otorhinolaryngologist.
A large amount of bleeding is a surgical emergency. IV access should be
obtained immediately and volume replacement should be initiated. The
tracheostomy tube should not be removed because it may be the best way to
ensure an airway. Frequent suctioning aids in preventing aspiration. If the site of
bleeding can be identified, direct pressure should be applied to the area.
Overinflating the cuff may tamponade a bleeding vessel and provide a temporary
treatment until it can be ligated.
Peristomal granulomas can usually be treated with topical antibiotics. In
refractory cases, cauterization with silver nitrate is indicated.
Home Ventilators
Some patients with tracheostomies will require home mechanical ventilation.
Caregivers may come in to the ED because the ventilator is alarming at home or
the patient is requiring higher levels of support or oxygen. Understanding the
basics of home ventilators is useful in the workup and management of
complications.
The low pressure alarm on the ventilator will sound if two consecutive breaths
do not reach the pressure limit; this is usually caused by a leak or disconnect. The
physician should start at the patient and work toward the ventilator, checking for
loose connections. Finally, the tracheostomy cuff should be evaluated for leaks
and the low pressure alarm should be confirmed to be set at the correct setting.
The high pressure alarm on the ventilator will sound when the pressure in the
circuit has increased. This can be caused by frequent coughing, tracheostomy
tube obstruction, kinks in the tubing, and water in the circuit. Because
tracheostomy tube obstruction is so common, the tube should be changed or
suctioned and the inner cannula of the tracheostomy tube changed as needed.
Increased oxygen or ventilator requirements suggest an infectious process and
appropriate testing should be obtained, including a chest radiograph and tracheal
secretion Gram stain and cultures. Hospital admission is often indicated for more
aggressive treatment.
If a patient with a tracheostomy tube and home ventilator is stable to be
discharged from the ED, it must be confirmed with the caregivers that they have
adequate battery life and oxygen for the drive home.
CEREBROSPINAL FLUID SHUNTS
Background
