A patient suffered significant bleeding during an attempt at percutaneous dilatational tracheostomy due to an aberrant anterior jugular vein. Bleeding was controlled with pressure temporarily, but quickly returned necessitating conversion to an open technique. We present an algorithm for the management of significant peri-procedural bleeding during this procedure. PDT is a safe and reliable technique and although significant bleeding during PDT is rare, having a plan on how to arrest bleeding while specialist assistance is sought is essential for when the situation occurs. We believe the above plan of prioritising the airway, while applying direct pressure provides a safe and effective method of arresting bleeding in the hands of non-surgical operators. Ultrasound remains a potential option for the operator to be fully aware of any vulnerable structures; however, studies are yet to prove that its use is associated with a lower incidence of bleeding complications.

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