• Yahia Akeely, Gary M Vilke, Hassan Alzahrani, Ibrahim Alshowaihi, Ashraf Alsaadani, Abdulrahman Rabah, Abdulrahman Turkistani, and Mohammad F Abosamak.
• Department of Emergency Medicine, Security Forces Hospital, Riyadh City, Kingdom of Saudi Arabia.
• J Emerg Med. 2021 Mar 1; 60 (3): 380-383.

BackgroundEndotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.Case ReportWe report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.Copyright © 2020 Elsevier Inc. All rights reserved.

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