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HWN Suggests

The bleeding tracheostomy

For bleeding at the stoma site, apply direct pressure, with or without hemostatic dressings. You can also cauterize with silver nitrate. For any bleeding deep to the stoma, have an assistant apply pressure at the base of the neck, in the sternal notch, to extrinsically compress the innominate artery. If the patient has a cuffed tube, hyper-inflate the cuff. Add air slowly to prevent rupturing the cuff. The target should be around 50ml of air. If the tracheostomy is uncuffed, replace it with a cuffed tube and hyper-inflate. Hyperinflation will work about 85% of the time. If it doesn’t, slowly withdraw the tube while pulling anteriorly to apply pressure to the anterior aspect of the trachea.…

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Survival Guide - Tracheostomy Hemorrhage

The majority of tracheostomy bleeds originate from the stomal region or are related to suctioning trauma and are self-limiting. Nevertheless, more serious causes of bleeding such as tracheoinnominate fistula (TIF) must always be considered and ruled out.

Airway Management of Massive Hemoptysis in a Tracheostomized Patient: A Clinical Approach

Early bleeding is usually local and related to factors like anticoagulation while late bleeding is related to tracheostomy itself. The innominate artery crosses from left to right at the ninth tracheal ring but can be as high as the sixth ring. Factors that can lead to TIF include pressure necrosis from cuff pressure, tracheal tube tip pushing against the trachea, placement too low (below the third ring), or local tracheal wall weakness due to radiation or steroids. Local hemostasis followed by definitive corrective surgery is required. Tracheal tube pulled forward with high cuff pressure can sometimes tamponade the artery while preparation is made to proceed to the operating room. Placement of index finger behind the sternum with thumb outside can help with tamponade. At this stage, tracheostomy is removed and OTI is done.

CORE EM: Common Tracheostomy Issues

Herald bleed in tracheo-innominate fistula: small self-resolved bleeding that is harbinger of subsequent bleeding. 50 % of cases have a herald bleed prior to a massive bleeding event (Grillo 2003). Even minor bleeding warrants evaluation in an OR setting with bronchoscopy. If flexible bronchoscopy is unrevealing then rigid bronchoscopy should be performed.

How To Manage Tracheo-Innominate Fistula

Sentinel bleeding may occur in more than 50 percent of patients, with peak incidence of three days to six weeks following tracheostomy. It is reported that massive hemorrhage occurring three days to six weeks after tracheostomy is TIF until proven otherwise. Vascular erosion from a tracheostomy tube requires at least 48 hours to develop.

Successful emergency management of a bleeding tracheoinnominate fistula

The acute haemorrhage was first managed with hyperinflation of the tracheostomy cuff that evidently ceased airway contamination and enabled satisfactory ventilation. The hospital’s massive transfusion protocol was initiated, and balanced blood product resuscitation (in 1:1:1 ratio) was commenced. With a view to translaryngeal intubation, direct laryngoscopy was attempted and the mouth and pharynx cleared of massive blood clots. It became apparent that some control of the ongoing haemorrhage was afforded by anterior displacement of the larynx with the laryngoscope. Effective tamponade was then achieved using a hyperinflated balloon on a Foley catheter that was introduced by direct laryngoscopy into the upper larynx above the tracheotomy stoma. With control of the bleeding, transport to the operating theatre was then undertaken for definitive management.

Tracheoinnominate Artery Fistula

Tracheostomy patients are infrequently seen in the emergency department, leading to an unfamiliarity around important anatomical considerations and tracheostomy hardware management. These individuals can harbour acutely life-threatening pathology, with the most feared being the tracheoinnominate artery fistula.

Tracheostomy emergencies: bleeding

Bleeding can be arbitrarily categorised into small (<10mls) or large (>10mls) volume bleeding. Small volume bleeding at a tracheostomy stoma may herald a major haemorrhage and the treating clinician must always thoroughly evaluate for the possibility of a trachea-arterial fistula.

Resources

Bleeding Tracheostomy

Haemorrhage from, or around, a tracheostomy site is both relatively common and potentially life-threatening - ‘early’ peri-operative bleeding is more common and usually benign. ‘late’ bleeding is potentially a life-threatening emergency.