What is the management for bleeding from a tracheostomy (trach) site?

Management of Bleeding from a Tracheostomy Site

The immediate priority is to differentiate minor bleeding from life-threatening tracheoinnominate artery fistula (TIAF), which requires emergency cuff hyperinflation or digital pressure followed by urgent surgical intervention with innominate artery ligation. 1, 2

Initial Assessment and Risk Stratification

Identify High-Risk Features for TIAF

• Suspect TIAF with any of the following: 1, 2, 3
  • Moderate to severe bleeding from the stomal site
  • Pulsation of the tracheostomy tube
  • Sentinel bleed (occurs in approximately 50% of TIAF cases before massive hemorrhage) 1, 2
  • Recent tracheostomy within 3 weeks (75% of TIAF presents within this timeframe) 3, 4
  • Percutaneous tracheostomy technique 3, 4
  • History of radiation therapy or chronic steroid use 3

Differentiate Bleeding Etiology

• Minor bleeding causes: traumatic suctioning, granulation tissue, local infection, or bleeding disorders 1
• Catastrophic bleeding: tracheoinnominate artery erosion requiring immediate intervention 1

Emergency Management Algorithm

For Suspected TIAF (Moderate to Severe Bleeding)

Step 1: Immediate Airway Control and Bleeding Tamponade 1, 2

• Hyperinflate the existing tracheostomy tube cuff immediately if present 1, 2
• If no cuff or inadequate control, insert a cuffed tracheal tube via the stoma with the tip placed distal to the fistula 1, 2
• Apply digital pressure directly through the stoma or externally to the innominate artery site (Utley Maneuver) 2, 3
• These maneuvers control bleeding in more than 80% of patients through direct tamponade 4

Step 2: Simultaneous Resuscitation 1, 2

• Initiate standard resuscitation measures per Advanced Life Support protocols 1, 2
• Activate massive transfusion protocol 3
• Obtain emergency blood products 3

Step 3: Definitive Surgical Management 2

• Immediate consultation with otolaryngology and cardiothoracic surgery 3, 5
• Emergency operative intervention in the operating room with personnel capable of performing sternotomy 1
• Division and ligation of both ends of the innominate artery is the definitive treatment 2
• Neurological sequelae from innominate artery ligation are rare 4

For Minor Bleeding

Conservative Management 1

• Careful observation with most cases settling without surgical intervention 1
• Identify and address the underlying cause:
  • Review suctioning technique if traumatic injury suspected 1
  • Perform flexible endoscopic evaluation through the tracheostomy tube to assess for suction trauma or granulation tissue 1
  • Counsel caregivers on proper suctioning technique 1

Critical Pitfalls to Avoid

Do Not Delay Recognition of TIAF

• Any bleeding occurring 3 days to 6 weeks after tracheostomy should be considered TIAF until proven otherwise 4
• A sentinel bleed may briefly resolve before massive hemorrhage occurs 1, 2, 3
• Peak incidence is 7-14 days post-procedure 4

Avoid Inappropriate Airway Interventions

• Do not attempt oral endotracheal intubation unless you have confirmed the patient has a patent upper airway 1
• In patients with upper airway obstruction (the reason for tracheostomy), oral intubation will fail and waste critical time 3

Risk Factors for TIAF Development

• High cuff pressure causing pressure necrosis 4
• Malpositioned cannula tip causing mucosal trauma 4
• Low tracheal incision site 4
• Prolonged intubation prior to tracheostomy 4

Post-Emergency Considerations

After Bleeding Control

• Intensive monitoring is crucial following innominate artery ligation 2
• Assess for other tracheostomy complications including infection, tracheomalacia, or false tract formation 1
• Ensure bedside emergency equipment is complete: functional suctioning system, oxygen source, manual resuscitation bag, and complete tracheostomy kit 6