Dr Kelly Thornbury1, Dr Henry Shepherd1, Dr Rowan Gillies1
1Royal North Shore Hospital
Tracheostostomies are frequently required in major burns patients who require ongoing operative management and ventilatory support. Long term tracheostomy complications include vocal cord injury, tracheal and subglottic stenosis and tracheooesophageal fistula formation. Rarely, tracheostomies have been reported to eroded the innominant artery. Tracheoinominate artery fistulae have an incidence of 0.1-1% and are usually fatal without prompt surgical intervention (Grant, 2006). We report a case of a 42 year-old spray painter who sustained 82% burns to his body when paint ignited. He was intubated at the scene and subsequently required a tracheostomy to maintain his airway. This was performed ten days after the intubation, once the skin graft to his anterior neck was stable. One month after the percutaneous tracheostomy was performed the patient started to bleed profusely from the tracheostomy site and into his mouth. The tracheostomy cuff was inflated in an attempt to tamponade the bleeding, a technique reported in the literature. This proved unsuccessful and prompted a massive transfusion protocol. The patient was reviewed urgently by ENT and Cardiothoracic teams and he subsequently underwent a sternotomy in theatres. A tracheoinonminate artery fistula was subsequently identified and successfully treated.
To our knowledge, this is the first published case of a major burns patient to have developed and survived a tracheoinominate artery fistula. Timely identification and surgical intervention were crucial to his survival. Subsequently there have been no further tracheostomy related complications for this patient.
Accredited Registrar Royal North Shore Hospital