Worst Case Scenario: Head and Neck

by Andria RN · 0 comments

in ICU,Podcast,Uncategorized

Download! What to do if your patient has a seizure, vomits blood or self-extubates, etc.
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In this crazy job called nursing, everything that can go wrong WILL go wrong at some point in your career.  I am dedicating this post to some worst case scenarios.


1.  Your patient begins to have seizure activity.

Ativan IV, pad the siderails, patient may need to be intubated, consult Neurology and start prophylactic meds like Dilatin or Keppra.  Neuro may want to do an EEG or head CT or both.  An OGT or NGT might be a good idea after seizure has resolved to help prevent aspiration.

2.  Your patient has a decreased in LOC, AMS, new onset confusion.  

Assess your patient for any other neurological deficits or vital sign changes.  If the patient is at high risk for falls, take appropriate precautions like bed alarm and possible restraints or mittens until you can determine the cause. Notify the physician.

Depending on the patient’s history- the physician may order a variety of interventions e.g. Stat Head CT, pan cultures to screen for an infectious process, lab work to check for electrolyte imbalances (sodium levels, ammonia levels, etc.) or a stat ABG to determine oxygenation status.

If you have a Neuro patient with a sudden decline in LOC or a change in their Neuro exam (for example, the patient was following commands and now is not)- you will likely do a stat Head CT and those results will determine the plan of care.

3.  Your Neuro patient has high ICP values.

Depending on the cause of the problem, Neurosurgery may place an EVD or take the patient to IR to do a coiling or clipping or craniotomy in the OR.

If the patient has an EVD, the drain may be lowered to allow for more CSF drainage.  The patient may need hypertonic solutions (3% NS) or an osmotic diuretic (Mannitol).

If ICP’s are related to patient activity, sedation may need to be increased.  In severe cases, patient may need to be placed into a barbiturate coma.

External Ventricular Drain

4. Feeding tube problems are endless.

Nasal Bridle to hold FT in place

Patients do not like to have feeding tubes (FT) inserted.  You may need a one time dose of Ativan, Fentanyl or Morphine, etc. to calm your patient down long enough to place the tube.  *Do not use the FT until it is confirmed that it is in the correct place and not in the lungs.  Our hospital requires x-ray verification.  Once the tube is in and taped firmly onto the nose- there are some things that can go wrong…

If the FT is dislodged or gets pulled out, STOP THE FEEDINGS! If the tube has been slightly dislodged- re-secure and shoot a repeat x-ray.  If the tube is hanging all the way out, d/c the FT and insert a new one.  *Our hospital just started using “bridles” which secure the feeding tubes to the patient’s nasal septum so if the patient pulls on the tube- it causes pain and they stop.  Instead of restraining patients who attempt to manipulate the FT, try mittens!

**If the FT becomes clogged, try flushing it.  You can try warm water and anything with carbonation (soda pop, ginger ale) to try to break up the clog.  If nothing works, you may have to d/c and reinsert.

If the FT is kinked or coiled on the x-ray, you will likely not be able to get any feedings down the tube so you will have to d/c the FT and insert a new one.

Check residuals by pulling back on the FT with the syringe.  If residuals are large, do not reinsert the residual and decrease or stop the rate of TF (notify physician).  If residuals are moderate, decrease the rate of TF.  If the residuals are small, the rate of TF is probably ok.  Check residuals every 4 hours at least or more frequently as needed.  Also check residuals if you stop hearing bowel sounds, bowel sounds are hypoactive and/or patient complains of pain or nausea.

Have Suction ready!


5.  Your patient is vomiting.

IV Zofran, place NGT or OGT to low continuous suction or low intermittent suction to suction out the stomach contents.  If the patient is wearing a bipap mask or is intubated, they’re at even higher risk for aspiration so take aspiration precautions!

6.  Your patient is vomiting blood (Hematemesis).

Take aspiration precautions, Notify physician, Consult GI, stat H&H, possible EGD to determine cause of bleed.  During the EGD they may be able to fix the issues.  Depending on frequency and severity of hematemesis and patient stability- the MD may order serial H & H’s and/or blood transfusions.  Patient may be sent to interventional radiology to search for and hopefully resolve the cause of the bleed.  If the patient has ruptured esophageal varices- a Sengsten Blakemore tube may be placed by the MD.  If rapid transfusion is necessary you may need to use a Level 1 Infuser.

7.  Patient has a white tongue.

This is probably thrush and the patient will be placed on nystatin swish and swallow.  Paint on the tongue with an oral care brush as ordered.

Oral Thrush


8.  Patient is biting Endotracheal Tube (ETT) causing high pressure alarms.

Have your Respiratory Therapist place a bite block to prevent the patient from occluding the tube.  In a pinch, you can use a syringe to lodge between the patient’s teeth.  Increase sedation if possible.

Bite Block: Goes around ETT and prevents patient from clamping down on ETT

9.  ETT is dislodged or patient self-extubates.

If ETT is supposed to be taped at 23 lip line and you see it at 26 lip line, have RT or physician advance tube to 23 and re-shoot chest xray to confirm placement.  If patient’s oxygenation status is declining, you may have to remove the ventilator and bag the ETT.  If this does not improve oxygenation, you may have to completely d/c the ETT (have suction ready and don’t forget to the deflate cuff first) and then bag the patient.  You can call a respiratory code to have the patient reintubated.

If the patient self-extubated and the patient is alert- grab a nasal cannula or a venti mask and see if the patient can fly on their own.  If the patient is not showing signs of respiratory distress, get a stat ABG.  And of course, notify the physician.  If the patient self-extubated and is now having agonal breathing, of course you should be bagging the patient and calling a respiratory code to have the patient re-intubated.

**Appropriate use of restraints, appropriate sedation and frequent monitoring can help prevent self-extubation but even with all of these precautions- it does happen!

10.  Bleeding around the trachestomy site.

If this is a fresh trach, bleeding for 1-2 days is normal.  If the site continues to ooze, notify the physician.  The wound may need to be packed or the bleed may need surgical ligation.  If you are suctioning bloody secretions this may be normal with a fresh trach.  If the trach is no longer new and secretions are bloody, make sure the air is humidified, limit suctioning when possible, use a soft suction (red rubber suction), or possibly the MD may order epi in an inhaled form to constrict the bleeding vessels.  *I’ve seen this done a few times in end stage Pulmonary Fibrosis patients.


11.  The trach becomes dislodged.

**This is why you always make sure you have an obturator close by (in the appropriate size) whenever you have a patient with a tracheostomy.

Insert the obturator into the outer cannula and reinsert into the tracheostomy site.  If you have a new outer cannula close by- use it.  If you are desperate- you will have to use the “used” one that just came out of the neck.

The obturator is the hardened piece that fits inside the outer cannula to make it firm enough to be re-inserted.  The outer cannula alone is too flexible.  Maintain oxygenation status.  Bag mask if necessary and notify the physician.  You may possibly call a respiratory code if oxygenation status is poor or you can’t re-insert the cannula.  If it makes you feel better- in two years I’ve never heard of anyone having to actually do any of this.  But it’s always good to know what to do in the worst case scenario!



When you go to work, you have no idea what you're in store for!




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