Post by @FTeranmd
Clinical scenario: 72 yo F with history of lung carcinoma with permanent trachestomy placed four months prior presentation, brought by EMS with profuse, active bleeding from the stoma site. Patient is ventilator dependent and is being assisted with BVM at arrival. Per nursing home staff bleeding was noted an hour prior presentation and there was no history of unusual manipulation or trauma. Previous management had included aspiration and local pressure with dressings. Patient’s O2 Saturation is 97% at arrival on 40% FIO2. BP is 102/60 and HR 100. Mental status is normal.
What the next step in management of this patient?
Answer: call for help!
Critical interventions are management of the airway and consultation to specialist for definitive management, as bleed might need surgical intervention in cases where arterio-tracheal fistula is the cause of hemorrhage.
Key question: When was the tracheostomy placed?
Post-tracheostomy hemorrhage may be classified into two broad categories: “early” and “late”. Peri operative (early) bleeding is most common, usually result of manipulation or inadequate surgical hemostasis and is usually benign. In the case above, the fact that patient presented several months after tracheostomy was placed (considered late bleeding), is concerning as the bleeding could be more likely result of erosion and rupture of one of the blood vessels around the ostomy site, including life-threatening arterial bleed.
The main affected vessel is the right brachiocephalic artery, which is also known as the innominate artery. In the current case, patient’s bleed was deemed to be coming directly from the ostomy site. Airway was patent, but patient required constant aspiration to remove large amounts of clots from airway. Bedside rigid tracheoscopy by ENT showed active bleeding but was unable to identify source. Given hemodynamic stability and airway patency, patient was taken emergently to the OR for surgical exploration. In the OR a tracheo-innominate fistula (TIF) was found as the cause of bleed, which was managed with ligation of the innominate artery. Tracheo-innominate fistula is a rare yet life-threatening condition with a reported incidence between 0.1–1% after surgical tracheostomy. The hallmark is massive arterial bleeding either via or around the tracheostomy.
Approach to the Bleeding Tracheostomy in the ED
1. Call for help: fiberoptic tracheoscopy is useful to identify source of bleed in some causes, but often patient will need immediate surgical exploration
2. Airway management:
– Check tracheostomy cuff and inflate if needed.
– Constant aspiration with Yankauer from tracheostomy
– Ventilation and oxygenation as needed
– In the case of active profuse bleed with concern for aspiration or asphyxia due to blood, ET intubation can be attempted with tube cuff inflated distal to tracheostomy site.
3. Temporazing measures to attempt hemostasis:
– Over inflation of the tracheostomy cuff has been described as a temporizing meausre to control bleeding when TIF is suspected (proposed mechanism is mechanical occlusion of the fistula).
– Applying finger pressure to the root of the neck in the sternal notch
Additional general measures:
– Coagulopathy reversal if needed, blood products and resuscitation
– Involve ENT and vascular surgery early as definitive repair of massive bleeds is often complex
Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheo-innominate artery erosion: successful management of a devastaing complication. Ann Surg 1976; 184(2):194-204.
Allan JS, Wright CD. Tracheoinnominate fistuala: diagnosis and management. Chest Surg Clin NA. 2003;13(2):331-41.
Kapural L, Sprung J, Gluncic I. Tracheo-innominate artery fistula after tracheostomy. Anesth & Analg 1999; 88(4):777-800.
Standards for the care of adult patients with a temporary tracheostomy (via The Intensive Care Society website) accessed on 10/27/14: http://www.ics.ac.uk/EasySiteWeb/GatewayLink.aspx?alId=2212