Fatal connection: death caused by direct connection of oxygen tubing into a tracheal tube connector.
During cardiopulmonary resuscitation, oxygen extension tubing was mistakenly connected into the tracheal tube connector. As a result, the patient recovering from hypovolemic cardiac arrest died because of pulmonary barotrauma. Similar cases have been reported. We suggest that a worldwide equipment performance standard be developed to prevent future occurrences and describe an example of connectors that would prevent such misconnections.
Singh
Surinder
S
*Department of Anesthesiology, Indira Gandhi Medical College, Shimla, India; and †Department of Anesthesiology, University of Arizona, Tucson, Arizona.
Loeb
Robert G
RG
D000328:Adult; D001469:Barotrauma / Q000209:etiology*; D016887:Cardiopulmonary Resuscitation; D017809:Fatal Outcome; D005260:Female; D006323:Heart Arrest / Q000628:therapy; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000295:instrumentation*; D019300:Medical Errors; D006473:Postpartum Hemorrhage / Q000628:therapy; D011247:Pregnancy; D012769:Shock / Q000628:therapy