You are called urgently to the bedspace of a 58-year-old patient in the ICU, due to profuse bleeding at the site of a five-day-old tracheostomy.
a) List the potential causes for post-tracheostomy bleeding, under the following headings.
i. Early (<72 hours)
ii. Late (>72 hours)
(40% marks)
b) Outline your emergency assessment and management plan for this patient.
(60% marks)
College answer
Aim: To allow the candidate to display management of a common issue in ICU.
Key sources include: A common clinical problem in the ICU. CanMEDS Medical Expert.
Discussion: Most candidates did well in this question. The question clearly states profuse bleeding, so most candidates went straight to assessment and management as an emergency airway problem which is reasonable and appropriate. All candidates mentioned tracheoinnominate fistula as a cause of late tracheostomy bleeding but not infection which is more common. Candidates who mentioned both causes displayed a greater understanding of the topic and were marked accordingly.
Unsuccessful candidates had an insufficient list of causes and poor structure to manage tracheostomy bleeding. Few gave details of what they would seek in the history to help diagnose the site of bleeding. Some candidates mentioned procedural detail but not the rationale for action. This would have improved their answer and displayed a senior, mature approach to the situation.
Discussion
- Early tracheostomy bleeding complications (<72 hours)
- Bleeding from the surgical wound - which can be profuse if it is exacerbated by poor skin tension (eg. an incision which is too large for the tracheostomy tube), or by anticoagulation, or because the patient keeps moving randomly.
- Inadvertent puncture of an anterior jugular vein. This risk can be modified somewhat by performing unskilled bedside ultrasonography of the pretracheal tissue before you go ahead with your percutaneous tracheostomy. Hatfield et al (1999) reported on a series of such ultrasound-secured tracheostomy procedures during which various little veins were identified and either avoided or ligated prior to tracheal puncture.
- Injury to the thyroid. A fair few tracheostomies seem to puncture it (Dexter et al, 1995).
- Injury to the inferior thyroid artery or vein would be very unlucky, but is listed by Bradley (2009) as one of the possibilites.
- Injury to the trachea. A tracheal tear is less likely in this day of brochoscope-guided tracheostomy, but there is definitely a possibility that the diator, guidewire or subsequent suctioning has resulted in tracheal injury.
- Haemorrhage from an unrelated pulmonary source that has absolutely nothing to do with the tracheostomy is definitely a possibility
- Late tracheostomy bleeding complications (>72 hours)
- Perioperative site infection is apparently the most common cause
- Tracheitis can occur as the result of frequent suctioning or as an unrelated infection
- Granulation tissue being injured by movement and suctioning is mentioned by all resources, but has no references associated with it, suggesting that
- Erosion of the tracheal wall which may be more common with an eccentrically placed (i.e. off-centre) tracheostomy
- Erosion of major paratracheal vessels which also tends to happen if the tracheostomy is eccentric
- Tracheoinnominate fistula which is the cause of bleeding in less than 1% of bleeding tracheostomy cases
- Emergency assessment and management plan
- Immediate risk assessment
- Assess whether the patency of the tracheostomy is immediately compromised
- Determine whether the bleeding is minor or major
- Determine whether it is originating from inside the ttracheostomy or whether there is bleeding around the tracheostomy
- Non-threatening bleeding
- Bleeding is regional (skin, wound, etc) - adrenaline soaked gauze, local lignocaine/adrenaline injection, cyanoacrylate skin glue,
- Bleeding is coming from the trachea or bronchi - tranexamic acid nebs, adrenaline nebs, bronchoscopy to identify source and potentially referral to definitive management by whoever handles the rigid bronchoscope in your hospital (either respiratory or ENT)
- Life-threatening severe bleeding
- Assess ventilation and oxygenation
- Commence 100% FiO2
- Pass suction catheter to assess tracheostomy patency
- Attach EtCO2 monitoring to determine that there is ventilation
- Assess whether there is blockage of bronchi by testing lung compliance (eg. manually bagging the patient, or attaching the patient to the ventilator to measure the tidal volume and pressure)
- Prepare for transfusion
- Achieve venous access, send G&H and contact blood bank to prepare for massive transfusion
- Assess the site of bleeding, if the volume of blood loss allows time for bronchoscopy
- Bronchoscopy may be useful to suction any clots, and may reveal the siteof bleeding to be the lung, rather than the tracheostomy
- If the bleeding is definitely not coming from the lungs, then it may be useful at this stage to intubate the patient orally to prevent soiling of the lower airway
- Otherwise, contact specialist services and prepare for theatre, as the most likely causes cannot be managed medically:
- ENT, to help repair the trache site
- Interventional radiology, to help embolise eroded vessels
- Cardiothoracic surgery, in case this is a tracheoinnominate fistula, as this calls for a proper sternotomy
- While waiting for definitive repair:
- Overinflate the tracheostomy cuff (to put pressure on an arterial bleeder)
- If this does not control the bleeding, intubate the patient orally to prevent soiling of the lower airway
- Attempt to gain control of the fistula bleeding by digital compression (the "Utley manoeuvre")
It is interesting that the college frowned upon trainees who immediately mentioned tracheoinnominate fistula. This extremely rare but almost uniformly fatal complication was actually the subject of an entire 10-mark question (Question 14 from the first paper of 2020) and occupies literally half of the paper by Bradley (2009) which is supposed to be all about different causes of post-tracheostomy bleeding. The trainees fixated on this complication can rightly defend themselves by pointing out that this high-stakes low-frequency even is exactly the sort of thing one should be well-prepared-for by their foundational training, as the management is very specific and requires calm expertise (whereas any primate can be trained to pack adrenaline-soaked gauze around the stoma).