Originally adapted from Cliff Reid’s Resus.ME post on Bleeding Tracheostomy
Haemorrhage from, or around, a tracheostomy site is both relatively common and potentially life-threatening
- ‘early’ peri-operative bleeding is more common and usually benign
- ‘late’ bleeding is potentially a life-threatening emergency
- 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)
- operative injury to a significant vessel (e.g. anomalous vasculature)
Late (e.g. >72 hours)
- granulation tissue
- infection at the stoma site
- tracheo-innominate fistula
- erosion of an adjacent vessel
Also note that:
- An underlying bleeding diathesis may be present
- Usual causes of hemoptysis may be responsible for bleeding from a tracheostomy
Haemorrhage (any of these features may be absent!)
- aspiration of blood
- bleeding beside the tracheal cannula
- bleeding from the tracheostomy tube lumen
- may appear to be naso-oropharyngeal haemorrhage, especially where the contact between the tissue and the cannula is tight
- massive, lethal bleeding may follow a small, apparently insignificant, sentinel bleed in the preceding hours in the case of a tracheo-innominate fistula
- pulsation of the cannula (may be absent)
- FBC and coags (check for bleeding diathesis)
- crossmatch (may require transfusion, especially if surgical intervention required)
- angiography (may be negative)
- bronchoscopy (may be negative)
Urgent surgical intervention, without delay for investigation, may be warranted
Assess for life-threats and call for help
- ABC approach
- enlist senior medical and nursing staff, other health professionals with tracheostomy care skills (e.g. respiratory therapist, physiotherapist)
- blood clots may need to be suctioned +/- bronchoscopy if sufficiently stable
- provide high flow oxygen via tracheostomy tube and facemask (if tracheostomy tube is cuff down or removed)
Bleeding (especially if tracheo-innominate 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
- optimising 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 is required in an adult depending on the type and size of the tracheostomy tube
- Correct coagulopathy and replace blood products as required
- ensure adequate IV access
Urgent referral for surgical exploration and repair
- ENT or maxillofacial surgeon and a vascular surgeon
- ligation and resection of the pathological segment of artery, rather than reconstruction, is generally preferred
- sometimes, surgical repair requires cardiopulmonary bypass, and so a cardiothoracic surgeon may also be needed
- if patient stabilises, angiography may help identify the source of bleeding +/- allow angioembolisation
- this situation may be rapidly 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
- Bradley PJ. Bleeding around a tracheostomy wound: what to consider and what to do?. J Laryngol Otol. 2009;123(9):952-6
- Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119.
- Hafez A, Couraud L, Velly JF, Bruneteau A. Late cataclysmic hemorrhage from the innominate artery after tracheostomy. Thorac Cardiovasc Surg. 1984;32(5):315-9
- Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-55.
- Richter T, Gottschlich B, Sutarski S, Müller R, Ragaller M. Late life-threatening hemorrhage after percutaneous tracheostomy. Int J Otolaryngol. 2011;2011:890380.
- Singh N, Fung A, Cole IE. Innominate artery hemorrhage following tracheostomy. Otolaryngol Head Neck Surg. 2007;136(4 Suppl):S68-72.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.