Tracheostomy bleeding

Background

Tracheostomy Sizes

(1) Thyroid cartilage (2) Cricothyroid ligament (3) Cricoid cartilage (4) Trachea (A) Cricothyrotomy site (B) Tracheotomy site
Tracheotomy in situ
1 – Vocal folds
2 – Thyroid cartilage
3 – Cricoid cartilage
4 – Tracheal rings
5 – Balloon cuff
Shiley™ trach tube
  • Average size:
    • Adult: 5-10mm
    • Peds: 2.5-6.5mm

Tracheostomy vs laryngectomy

It is important to differentiate between tracheostomy vs laryngectomy

  • If laryngectomy[1]:
    • The stoma is the only way to ventilate the patient.
    • Patient cannot be orally intubated

Clinical Features

  • Minor bleeds within first few days usually due to:
    • Lack of hemostasis
    • Tube suction and manipulation
    • Tracking of blood from nearby surgical site

Risk Factors

Differential Diagnosis

Tracheostomy complications

Evaluation

  • Large bleed is tracheoinnominate fistula until proven otherwise

Management

  • Local Bleeding
    • Use silver nitrate if bleeding source is identified
  • Brisk Bleeding
    • Tracheoinnominate artery fistula (TIF) until proven otherwise
      • Most patients present within first 3wk after tracheostomy
      • Very high mortality rate
      • Delegate team member to obtain surgical assistance, especially with massive bleed
      • Treatment:
        1. Hyperinflate the cuff (85% successful), up to 50 cc to tamponade bleeding
        2. If above fails, withdraw tube while placing pressure against anterior trachea
          • ETT from above (as long as there is no laryngectomy)
          • Apply digital pressure of innominate artery against the manubrium from inside tracheostomy tract
          • Go to the OR with finger tamponade innominate artery
        3. If above fails, place a cuffed ET tube to prevent pulmonary aspiration of blood
        4. Correct coagulopathies and administer blood products as needed
      • Requires emergent OR exploration and definitive management
Hyperinflation-leveraging against innominate.jpg
Finger tamponade.JPG

Disposition

  • Emergent OR for TIF
  • Most minor bleeds do not require admission and observation if controlled in ED
  • Consult with primary surgeon for new tracheostomies

See Also

External Links

References

  • Allan JS, Wright CD. Tracheo-innominate fistula: diagnosis and management. Chest Surg Clin NA. 2003;13(2):331-41.