International journal of legal medicine
-
An 80-year-old woman was intubated with a spiral endotracheal tube via a tracheal stoma during an arytenoidectomy. After being connected to the ventilator, the victim quickly became cyanosed, showed a decrease in blood pressure, and fell into cardiopulmonary arrest. Despite continuous resuscitation, the victim died. ⋯ Tracheal perforation is a rare, but life-threatening complication following a tracheostomal intubation. The inappropriate use of a tracheal tube stylet, guiding catheter, dilating forceps, and oversize tracheal tube have been demonstrated to cause airway injuries. However, fatal incorrect intubation with a spiral endotracheal tube via a tracheal stoma that resulted in death has not been reported previously.