(1147) Tracheoinnominate Fistula in a Burn Patient With Suspected Inhalation Injury

Introduction: Burn patients with an inhalation injury often have a difficult time liberating from the ventilator and require a tracheostomy to assist in ventilator weaning. Tracheoinnominate fistulas (TIFs) are a rare but often fatal complication of tracheostomy, often occurring in the first few weeks after a tracheostomy is placed. The inhalation of smoke or chemical fumes as part of a burn injury can make the airways edematous and friable. Patients with a tracheostomy in the setting of an inhalation injury may be at increased risk for airway complications.

Description: A 44-year-old female with a past medical history of depression and polysubstance abuse presented to our burn center after self-immolation after being found inside a vehicle using gasoline as an accelerant. She had a 6.25% total body surface area burn and suspected inhalation injury due to inhalation of the gasoline vapors. She was intubated in the field prior to admission, had two failed extubation attempts over the next two weeks, and received steroids each time due to concerns for airway edema. She underwent an uncomplicated percutaneous tracheostomy on hospital day 17. On hospital day 22, patient had sudden profuse bleeding inside and around her tracheostomy tube as well as from her mouth. She progressed to respiratory then cardiac arrest with a suspected tracheoinnominate fistula. Trauma surgery, otolaryngology, and anesthesia all arrived to bedside but the ICU team was unable to secure a viable airway and patient died after nearly 40 minutes of resuscitation attempts. Autopsy results demonstrated a fistula between the trachea and the innominate artery. The combination of edema, steroids, prolonged intubation, and a tracheostomy procedure are all risk factors of a fistula, and the added insult of inhaled fumes created an even more hostile airway

Discussion: Patients with inhalation injuries from burns are at increased risk of difficult ventilator weaning requiring tracheostomies and the associated risks. Even with rapid intervention and appropriate resuscitation efforts, tracheoinnominate fistulas continue to have high mortality rates, and the burn population is at special risk. We recommend further consideration of the implication of inhalation injury on the intubated patient to mitigate the risk of complications.