Questions one needs to ask before one yanks the tracheostomy out are:
Previous hot cases with this sort of theme to them can be found below.
The standard introductionAsk examiners about turning up the lights The environmentThe physical examinationThe details of this section can be seen in the opposite column. The obs and investigations
The Presentation |
The Physical Examination in Brief DetailAsk the examiners to sit the patient up Ask the examiners about any language barriers
Ask examiners to lay the patient flat. |
Look around the room. A prolonged ICU stay leaves artifacts around for you to notice.
A pacing box?
Sensitivity and pacing threshold may not be relevant.
Essentially, the monitor screen guides you to decide whether oxgenation is adequate, and whether the patient is hemodynamically stable.
One can ask the examiners the following questions:
One should ask about the following parameters:
One should ask to look at the pressure-volume loops.
If the patient is on a blow-over T-piece or something similar, ask about the gas mixture: what is the FiO2? How long has the patient been on blow-over?
There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state; in the evaluation of decannulation readyness one should focus on the amount of pain being caused by the drain, and whether there is a plan to remove it in the near future.
The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.
A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:
These questions may go unanswered.
This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.
The sedation should be off, or minimised.
Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.
Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:
Performing the GCS should be the first step.
The level of consciousness is an important determinant of decannulation success.
A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:
One has just performed a GCS assessment; one is still holding the hands.Now, time to look at them more closely.
First, one should spent a second assessing whether they are warm or cold.
Then, one can focus on the nails. Nail signs are numerous and deserve their own page.
In brief, the nail signs one could look for are as follows:
Clubbing Leukonychia
Nail lines:
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Onycholysis Koilonychia Splinter haemorrhages Nicotine stains Vertical nail ridges Horisontal nail ridges |
Done with the nails, one may want to briefly consider (and maybe even comment upon) the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.
Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until this stage.
Tone of the upper limbs
Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.
Asterixis
In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed.
The patient's ability to raise their arms also speaks volumes about proximal muscle power.
Cubital fossa
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
The examination of this patient's cranial nerves should be reasonably detailed.
The upper nerves should also be examined, but the money is in the gag and cough reflexes. It is important to determine whether the patient will be able to protect their airway from oropharyngeal secretions.
Thus, one should go through the full cranial nerve examination:
A Snellen chart is ideal, but probably will not be available.
The extubated patient should be able to read the time on the clock in the room.
One performs this test with each eye individually.
This tests CN II.
Ask the examiners to dim the room lights.
Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.
This tests CN II (afferent) and CN III (efferent).
The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.
A normal reflex is to blink.
This tests CN V (afferent) and CN VII (efferent)
The conscious patient will be able to follow the tip of the candidate's finger.
The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.
This tests CNs II, IV and VI.
Typically, this is performed by putting some pressure on the superior orbital notch.
The patient should either open their eyes or localise.
This tests CN V.
The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:
Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.
The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.
This collectively tests CN X and IX.
While on the subject of CN X, one may test the cough reflex by suctioning the trachea.
This tests CN X.
This is also a convenient time to ask about the volume and character of the secretions.
The conscious patient is asked to protrude their tongue, and move it from side to side.
This tests CN XII.
The uvula deviates away from the lesion.
This tests CN X and IX.
The conscious patient is asked to shrug their shoulders against resistance.
This tests CN XI.
The tracheostomy is the final destination in this sequence.
The objective of this part of the examination is to determine whether there is any sign of ongoing respiratorty pathology, and how severe it is - i.e. whether it will delay decannulation.
Palpation:
One puts both their hands on the chest to assess the symmetry of chest expansion.
Percussion:
One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.
Changes in percussion resonance may be worth commenting on.
Auscultation:
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.
The objective of this part of the examination is to determine whether the patient has cardiac failure sufficiently severe to delay decannulation. If no pulmonary oedema was found on the auscultation of the chest, the cardiac examination should focus more on the right heart, and on the presence of features of pulmonary hypertension:
Palpation:
The clever candidate will make a big show of palpating both the apex and the right sternal edge.
Auscultation:
One should auscultate in the following sequence:
The various clicks and murmurs one encounters are discussed elsewhere.
For this, one should ask to lay the patient flat.
The objective of this examination is to determine whether sufficient unresolved abdominal pathology is present to delay decannulation. Specifically, unhealed abdominal wounds and abdominal distension are the main concerns.
Abdominal observation
Abdominal palpation
Abdominal percussion
Abdominal auscultation
The pelvic content would have been palpated during the abdominal examination.
The more important part of this examination is the groin.
At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.
Observation and palpation of the pelvis:
Examination of the lines
Examination of the genitals and rectum
Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.
One should ask to remove TEDs and compression stockings.
Leg muscle tone
The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend
Calf tenderness
In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.
This brings one to the feet, and to the beginning of the neurological examination.
The feet would have already been palpated to assess their temperature, and to look for pitting oedema.
Observation of the feet
One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.
Palpation of the feet
This should consist of palpating the dorsalis pedis and posterior tibial pulse.
Babinsky reflex
One should test the Babinsky bilaterally.
Clonus
One should attempt to assess clonus in both feet.
The neurological examination of this patient should focus on power. If there is insufficient proximal muscle power, the patient may fail decannulation, as they will remain bedbound and will have trouble clearing their secretions.
Power of the muscle groups may be tested in the following sequence:
Ask to see the obs chart. If it is not allowed, ask for the following:
One needs to show an interest in the following labs:
One should always ask for the following:
A specific issue to resolve is the swallowing. One should ask whether videofluoroscopy or fiberoptic endoscopy swallowing studies have been performed.
"Mr Bloggs is [ready / not ready] for tracheostomy decannulation."
"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"
"The following features are in favour of decannulation: [blah]"
"The following issues remain unresolved: [blah]"
"I would like to perform the following investigations to complete my assessment: [insert appropriate investigations]"
"The remaining management issues are as follows: [a brief list of management priorities]"
"To better prepare Mr Bloggs for decannulation, I would approach these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"
Number of previous hot cases in this topic: 2
Unspecified hospital in Adelaide |
59-year-old male, day 25 ICU, having presented with pneumonia on a background of COAD, anxiety and alcoholism. Clinical findings included and alert and co-operative patient with evidence of muscle wasting with preserved strength, an in situ tracheostomy with subglottic suction and reduced breath sounds at the bases. Candidates were directed to assess the patient and formulate a management plan including the consideration for decannulation. Discussion points included the management of pulmonary haemorrhage, and the significance of pseudomonas colonisation. |
Unspecified hospital in Sydney |
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