Introduction:
Tracheostomy is a surgical airway management procedure that involves making an incision on the anterior neck and opening a direct airway through an incision in the trachea.

Aim:
We report a case of a difficult tracheostomy complicated by massive immediate bleeding from the innominate artery that required a median sternotomy for vascular access and control.

Case study:
A 26-year-old lady with a short neck underwent a tracheostomy in a semi-emergency setting in view of prolonged intubation and frequent intubation prior. The tracheal incision was performed in between the 3rd and 4th tracheal rings and was complicated by massive bleeding from the innominate artery tear that was located below the sternum and necessitated a midline sternotomy procedure to access the artery. The artery was then repaired primarily and covered with a strap muscle that was swung over to the right and sutured to the periosteum of the right clavicle. She lost 6 L of blood, prompting a massive blood transfusion. Postoperatively, there was no bleeding from the wound, but she had an infected sternotomy wound that was managed with antibiotics and dressings. The tracheostomy tube care was uneventful.

Results and discussion:
The short-neck hyperextension during trachea exposure can cause major thoracic vessels and tracheal rings to move upward, leading to tracheal incisions being made lower than intended and risking major vessel injury.

Conclusions:
Imaging before surgery is recommended to delineate the anatomy and detect any major vessels present in the case of anticipated difficult tracheostomy.