1. Patients with tracheostomy bleeding can decompensate rapidly and a difficult airway should be expected. To prepare, advanced airway equipment should be gathered, and ENT and respiratory therapy should be notified.

2. Tracheoinnominate fistulas (TIF) have a high mortality rate and up to 50% are heralded by a sentinel bleed; therefore, all tracheostomy bleeds should be worked up for TIF unless the source of bleed is obviously local to the stoma and source is visualized.

3. Clinical red flags suggesting TIF include blood in the oropharynx, pressurized or large-volume bleeding, or trach pulsations in time to the patient’s heartbeat.

4. Imaging with CTA neck and chest is indicated for surgical planning only in hemodynamically stable patients.

5. Attempts to tamponade a tracheostomy bleed should include, first, cuff hyperinflation and, second, blunt finger dissection and compression of the innominate artery. Patients with TIF ultimately need operative correction or else they are certain to rebleed.