Gastrostomy, tracheostomy and central-line troubleshooting — OSCE

Station brief (candidate)

• Assess the child before the device, and recite the National Tracheostomy Safety Project paediatric emergency algorithm in order to resolve the obstruction.
• Manage the tube that has fallen out entirely, using the tract-maturity rule to decide between bedside replacement and ventilation-with-surgical-call.
• Recognise a late tracheostomy bleed as a tracheoinnominate artery fistula and give the immediate cuff, pressure and referral actions.
• State the disposition after a device emergency and the equipment that must be at the bedside. [4] [8]

Scenario detail

The child is a 4-year-old with cerebral palsy and chronic lung disease, with a gastrostomy and a tracheostomy in place for several months. On the ward the saturations fall to 80 per cent and the nurse cannot pass the suction catheter. The child is working hard and cyanosed. The examiner will ask you to talk through your immediate actions, then will reveal that the tube has fallen out entirely, and finally will probe a late-bleed complication. [4] [6]

Expected candidate performance

1. Child before device: Assesses airway and breathing first — work of breathing, colour, conscious level, saturations — and recognises that the deteriorating tracheostomy child is obstructed until proven otherwise. [4]
2. Tracheostomy algorithm: Recites the National Tracheostomy Safety Project algorithm in order — assess, suction via the tracheostomy, remove and clean the inner cannula, deflate the cuff, remove the tube and ventilate (by bag-valve-mask over the face if the upper airway is patent, or over the stoma if not), with early senior airway help; states the cardinal error of persisting with a non-functioning tube. [4] [7]
3. Decannulation and tract maturity: Recognises that the mature tract (several months, well beyond the seven-to-ten-day immature threshold) allows bedside reinsertion of a same-size tube with the obturator in place, without force, falling back to a one-size-smaller tube and then to ventilation-with-help if resistance is met; explicitly contrasts this with an immature tract, where blind instrumentation risks a false pretracheal passage and the response is ventilation by face mask and a surgical call. [3]
4. Late bleed: Recognises a tracheostomy bleed two to six weeks after insertion as a tracheoinnominate artery fistula until proven otherwise; gives the immediate actions — cuff hyperinflation to tamponade, withdraw the tube to reposition the cuff, firm digital pressure against the sternum to compress the innominate artery, and surgical and anaesthetic referral while securing the airway and large-bore access. [5]
5. Disposition and equipment: Places the child in a high-dependency or intensive-care setting after the event because the recurrence risk is highest immediately afterwards; states that the bedside must hold a spare tube of the same size and one smaller, a suction unit, a self-inflating bag, oxygen, and the bedhead algorithm. [3] [4]

Marking domains

• Correct assessment of the child before the device, and an accurate, ordered recitation of the National Tracheostomy Safety Project algorithm.
• Safe application of the tract-maturity rule to the decannulated tube, with explicit contrast between the mature and the immature tract.
• Recognition of the tracheoinnominate fistula red flag and the correct immediate cuff, pressure and referral actions.
• Appropriate disposition to high-dependency or intensive care and a complete bedside-equipment list.
• Understanding that the child is resuscitated before the hardware throughout. [4] [5]

Common fails

• Persisting with a non-functioning tracheostomy tube while the child deteriorates, instead of moving to the next step of the algorithm. [4]
• Forgetting the inner-cannula and cuff-deflation steps, or never removing the tube to ventilate. [4] [6]
• Treating an immature tract as mature and forcing a tube blindly down a fresh stoma, risking a false passage. [3]
• Dismissing a late tracheostomy bleed as trivial granulation rather than a tracheoinnominate fistula. [5]
• Omitting the spare-tube and equipment list at the bedside, or sending a freshly re-cannulated child to an unmonitored ward. [3] [4]