Management of tracheostomal hemorrhage complicated by obstructing clot in a post-laryngectomy patient presenting to a rural emergency department.

Total laryngectomy (TLE) results in the permanent separation of the respiratory and digestive tracts, requiring all airway interventions to occur exclusively via a neck stoma. Although airway obstruction in post-laryngectomy patients is uncommon, it can rapidly become fatal without prompt recognition and understanding of the altered anatomy. Here, we report the case of a patient with a recent TLE for squamous cell carcinoma, who presented to a rural Emergency Department (ED) in acute respiratory distress. Emergency Medical Service (EMS) providers reported profuse tracheostomal bleeding and hypoxia, with an oxygen saturation of 55 % on room air. On arrival at the ED, the patient was in severe acute distress with active hemorrhage and partial tracheostoma obstruction due to a large, gelatinous clot. Manual removal of the clot, along with an attached tracheobronchial cast, resulted in respiratory improvement. Ongoing hemorrhage was controlled with digital pressure in the suprasternal notch, intravenous tranexamic acid (TXA), and fluid resuscitation. Laboratory evaluation revealed a significant drop in hemoglobin from 12.1 g/dL at recent discharge to 8.9 g/dL, necessitating transfusion of two units of packed red blood cells. The patient was stabilized and transferred to a tertiary care center, where bronchoscopy revealed an anterior tracheal erosion as the source of bleeding and was eventually discharged in stable conditions. This case highlights a rare occurrence of life-threatening airway obstruction due to TLE-related hemorrhage at the tracheal stoma, for which Emergency Medicine providers should remain vigilant and prepare to act swiftly to secure the airway and prevent any catastrophic outcomes.