In the event of a massive hemorrhage from erosion of the brachiocephalic artery by an adjacent tracheo-stomy tube (Figure 27-2), control is obtained by firm finger compression downward at the site of bleeding and forward against the sternum (Figure 27-2A). An endotracheal tube is slipped into the trachea via the stoma, and the cuff is firmly inflated to minimize blood running into the tracheobronchial tree. The surgeon's finger or that of an assistant is held in place while the patient is expeditiously moved to the operating room, since cuff inflation alone may not control hemorrhage in this location. Exposure is best obtained through a collar incision at the level of the stoma plus a vertical sternotomy. Complete sternotomy at the outset will usually facilitate exposure and dissection under emergency circumstances (Figure 27-3A). Since sternal infection is a hazard, partial sternotomy through the manubrium angled into the third right interspace has been recommended.3 The upper abdomen is included in the potential operative field, in case an figure 27-1 Etiology of a fistula between the trachea and brachio-cephalic artery. Oblique views. A, Erosion of the artery, lying adjacent to a tracheal stoma, by the tube resting against the artery. The stoma has been made lower in the trachea than ordinarily. In younger patients, both the trachea and the artery rise into the neck with cervical extension. B, Fistula caused by tracheoarterial erosion by a high-pressure tracheostomy tube cuff or by an angulated tube tip. In this case, tracheostomy lies in the conventional site (second or third ring).
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