Case Presentation by Dr. Ayse Avcioglu
CC: Bleeding from tracheostomy
HPI: A 48 year old male presents from a long-term care facility for bleeding from his tracheostomy tube. Per nursing staff, about 10-20 cc’s of bright red bloody secretions were noted emanating from the tube which ceased spontaneously. Information was obtained from transfer records as patient could not provide information because he had recently suffered anoxic brain injury. Subsequently a surgical tracheostomy was performed 11 days ago. There is no history of fever, increased sputum production, night sweats or weight loss.
ROS: negative except for HPI
PMH: Diabetes, seizure disorder, hypertension, gunshot wound to chest
PSH: Tracheostomy, gastrostomy tube
Meds: Amlodipine, insulin, lorazapam, phenytoin, rosuvastatin, aspirin,
clonidine, isosorbide dinitrate, hydralazine
SH: history of polysubstance abuse including alcohol and cocaine.
FH: diabetes, chronic kidney disease
VS: BP: 180/86 mmHg, P: 75, RR: 24 T: 36.0 C, Pulse ox: 95% on room air
General: eyes open, no acute respiratory distress
HEENT: NC/AT, PERRL, borderline pallor, anicteric
Neck: supple. Tracheostomy tube with blood tinged sputum. Gauze saturated in blood. Minimal blood around stoma.
CVS: normal S1/S2, no murmurs, rubs or gallops.
Lung: scattered rhonchi
GI: abdomen soft, nontender, nondistended. Peg-tube in place.
Musculoskeletal: limbs atraumatic, nontender to palpation. Some atrophy of leg muscles.
Neuro: eyes open. Does not verbalize, withdraws to pain.
Skin: warm, dry, no decubitus ulcers, no petechiae
1. Given the time frame of the tracheostomy stoma creation, what is the most likely cause of bleeding?
B. Erosions secondary to tracheal suction
C. Granulation tissue
D. Tracheo-innominate artery fistula
2. What would be the next step in management?
A. Admit to the medical intensive care unit.
B. Attempt to suction trachea.
C. Obtain surgical consultation in the emergency department.
D. Place on humidified oxygen, observe for two hours, discharge if no
further bleeding occurs.
3. While examining the patient, a sudden massive gush of blood is noted from the tracheostomy and patient becomes hypoxic. What is the FIRST step in management?
A. Apply digital pressure through tracheal stoma and wheel patient to operating room
B. Call blood bank for immediate 2 units of O negative blood
C. Obtain stat surgery consultation for operative repair
D. Overinflate tracheostomy cuff
1. The answer is D. Bleeding around the stoma or hemoptysis in any patient with a tracheostomy should be fully investigated. The differential diagnosis of the cause of bleeding is based on the lag time between tracheostomy creation and subsequent bleeding. Tracheo-innominate artery fistula is a rare life-threatening complication of tracheostomy. It usually results from direct pressure from the tracheal cannula against the innominate artery, or from a cuff that is overinflated. The peak incidence of presentation is between the first and second week. About 50% of patients have a sentinel bleed which may be mild and should not be ignored because of the potential for sudden massive hemorrhage. (B, C) Hemorrhage occurring within 48 hours is usually associated with local factors such as puncture of anterior jugular or inferior thyroid veins, granulation tissue, erosions due to suction or coagulopathy. A. Bronchopneumonia would be more likely if the patient had a history of fever and increased purulent secretions.
2. The answer is C. When tracheo-innominate artery fistula is suspected, the patient must be evaluated by a surgeon in the emergency department and transported to the operating room for fiberoptic bronchoscopy with definitive surgical repair. A. The patient should ideally be admitted to a surgical services team who are familiar with the management of this complication as a delay in diagnosis may result in death through asphyxiation. B. If the bleeding has stopped and the airway is clear, it is best not to disturb clots in the trachea by suctioning or movement of the tracheostomy tube in order to prevent increased rate of hemorrhage. D. Observation followed by discharge would be inappropriate without further assessment of the source of bleeding. Consider more than 10 mL of blood to be arterial.
3. The answer is D. The first step would be to hyperinflate the tracheal cuff in an attempt to compress the artery against the sternal wall. This maneuver alone is successful in 85% of cases.
If this attempt fails, insert an endotracheal tube through oropharynx, remove tracheostomy tube and position the endotracheal tube cuff distal to bleeding site to protect airway. B. Calling the blood bank for blood transfusion may become necessary if bleeding continues, but airway management takes priority. C. Notifying the surgeon will become critical but is not the first step in management. A. If initial attempts to control bleeding are unsuccessful, insert index finger through stoma, compressing the trachea against the sternum. This is the most reliable technique to stop the bleeding. Hold continued pressure while simultaneously wheeling the patient to operating room.
Roberts and Hedges Clinical Procedures in Emergency Medicine. 5th ed. Pages 124-137.
Tintinalli’s Emergency Medicine. 7th ed. Pages 1592-1595.
Grant, C.A. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. British Journal of Anesthesia 96 (1): 127–31 (2006).