Senior Report 5.19

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

Allergies:  NKDA

SH:  history of polysubstance abuse including alcohol and cocaine.

FH:  diabetes, chronic kidney disease

 

Physical Exam

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

Questions: 

1.  Given the time frame of the tracheostomy stoma creation, what is the most likely cause of bleeding?

A.  Bronchopneumonia

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

Discussion

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.

Pressure of tracheal cannula against innominate artery

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.

Hyperinflation of tracheostomy cuff

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.

References:

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).

One Response

  1. 1. D. Tracheo-innominate artery fistula.
    2. C. Obtain surgical consultation in the emergency department.
    3. D. Overinflate tracheostomy cuff. This is successful in controlling 80% of hemorrhages. If this is unsuccessful, you can reintubate orally and apply manual compression of the innominate artery against the sternum while working on getting the patient to the OR.

    This is a good, concise resource:
    http://www.surgicalcriticalcare.net/Guidelines/post%20tracheostomy%20hemorrhage%202009.pdf

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