Iatrogenic tracheal laceration causing asphyxia.

Area of Science:

• Medicine
• Anesthesiology
• Pathology

Background:

• Endotracheal intubation is a standard airway management technique.
• Airway injury during intubation can lead to patient morbidity and mortality.
• Physician liability is a concern associated with intubation complications.

Observation:

• A 62-year-old woman developed lethal airway obstruction post-renal autotransplantation.
• The obstruction was caused by an intraluminal blood clot.
• Autopsy revealed a linear longitudinal tracheal laceration.

Findings:

• Tracheal laceration is a rare but potentially fatal complication of endotracheal intubation.
• Intratracheal bleeding, clot formation, and subsequent tracheal occlusion can result in asphyxia.
• This case underscores a critical, albeit infrequent, risk associated with the procedure.

Implications:

• Highlights the importance of recognizing and managing rare complications of endotracheal intubation.
• Suggests the need for careful assessment of airway integrity post-intubation, especially if complications arise.
• Emphasizes the critical link between airway trauma, bleeding, and fatal outcomes.