title: Iatrogenic tracheal laceration causing asphyxia.
abstract: Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.
authors.affiliation: Department of Neuropathology, Clinical Hospital Center Zagreb, Zagreb, Croatia. leo.pazanin@zg.t-com.hr
authors.forename: Leo
authors.initials: L
authors.lastname: Pazanin
authors.forename: Vilka Bekavac
authors.initials: VB
authors.lastname: Misak
authors.forename: Nedjeljka
authors.initials: N
authors.lastname: Goreta
authors.forename: Zvonimir
authors.initials: Z
authors.lastname: Mareković
authors.forename: Vedrana
authors.initials: V
authors.lastname: Petrovecki
mesh_terms: D000402:Airway Obstruction / Q000209:etiology / Q000473:pathology*; D001237:Asphyxia / Q000209:etiology / Q000473:pathology*; D005260:Female; D049429:Forensic Pathology; D006801:Humans; D007049:Iatrogenic Disease; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D022125:Lacerations / Q000150:complications / Q000473:pathology; D008875:Middle Aged; D013927:Thrombosis / Q000150:complications / Q000473:pathology*; D014132:Trachea / Q000293:injuries* / Q000473:pathology