Bleeding Tracheostomy

Reviewed and revised 10 June 2014; adapted from Cliff Reid’s Resus.ME post on Bleeding Tracheostomy

OVERVIEW

  • ‘early’ peri-operative bleeding is more common and usually benign
  • ‘late’ bleeding is potentially a life-threatening emergency

CAUSES

Early

  • suction/ manipulation of tracheostomy tube
  • bleeding from a nearby surgical site that tracks to the tracheostomy site (e.g. tracheostomy created at the time of oral reconstruction and neck dissection for cancer)

Late

  • granulation tissue
  • infection at the stoma site
  • tracheo-innominate fistula (massive bleeding may follow a small, apparently insignificant, sentinel bleed in the preceding hours)

An underlying bleeding diathesis may be present

Usual causes of hemoptysis may also be present

APPROACH

  • Assess ABCs and call for help
    – senior medical and nursing staff, other health professionals with tracheostomy care skills (e.g. respiratory therapist, physiotherapist)
  • Clear airway
    – blood clots may need to be suctioned
  • Bleeding (especially if tracheo-inominate fistula is suspected) may be temporarily reduced or stopped by:
  • — applying finger pressure to the root of the neck in the sternal notch, or by
    — optimise tracheostomy tube position and inflating the tracheostomy tube cuff (if present) with a 50ml syringe of air. Inflation should be done slowly and steadily to inflate the balloon to a maximum volume without bursting it, usually 10 to 35 mL depending on the type and size of the tracheostomy tube
  • Correct coagulopathy and replace blood products as required
  • Urgent referral for surgical exploration
    — ENT or maxillofacial surgeon and a vascular surgeon
    — sometimes, the damage can only be repaired utilising cardio-pulmonary bypass, and so a cardiothoracic surgeon may also be needed
  • Consider palliation
    — this situation may be fatal
    — it may be the mode of death for some patients with head and neck cancers
  • If settles and is easily controlled, investigate for other causes (e.g. pulmonary causes of hemoptysis)

References and Links

FOAM and web resources

  • Resus.ME — Bleeding Tracheostomy
  • UK Intensive Care Society’s ‘Standards for the care of adult patients with a temporary tracheostomy‘

 

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