A 22-year-old woman is involved in a major motor vehicle accident and receives a tracheostomy during her hospitalization. Five days after placement of the tracheostomy she has some minor bleeding around the tracheostomy site. Which of the following is the most appropriate immediate therapy?

A rare but deadly complication of a tracheostomy is a tracheoinnominate aery fistula (TIAF); when suspected, the diagnosis should be confirmed or ruled out in the operating room. TIAFs can occur as early as 2 days after tracheostomy or as late as 2 months after the procedure. It is often associated with low placement of a tracheostomy (distal to the second and third tracheal rings). The patient may have a sentinel bleed in 50% of TIAF cases, followed by a very impressive bleed. If a sentinel bleed is suspected, the patient should be transpoed immediately to the operating room for bronchoscopic evaluation. Initial maneuvers for management of a TIAF include overinflation of the cuff on the tracheostomy or reintubation from above followed by removal of the tracheostomy and finger compression of the innominate aery against the sternum through the tracheostomy wound.