title: Iatrogenic Burns of the Neckline in a Patient with Tetraparesis During Tracheotomy.
abstract: The paper presents a case of an atypical iatrogenic complication after tracheotomy analyzed on the basis of the case dossier materials submitted to the authors by the court of justice to prepare a forensic medical opinion concerning the correctness of the medical procedure. A 37-year-old woman was brought by the ambulance service to the hospital with acute respiratory failure due to post-tracheostomy tracheal stenosis. Tracheotomy was performed on an emergency basis. The patient suffered severe burns of the chest and neck. The experts concluded that the most probable cause of the incident was electrocautery-induced ignition of the disinfectant used for cleaning the skin before the surgery. It was established that with correct handling of the procedure, the aforementioned incident should not have taken place. Therefore, it cannot be regarded as a normal complication inherent in the risk associated with the procedure, but as a consequence of a medical error.
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Anna
authors.initials: A
authors.lastname: Smędra
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Ewa
authors.initials: E
authors.lastname: Meissner
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Maciej
authors.initials: M
authors.lastname: Barzdo
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Przemysław
authors.initials: P
authors.lastname: Grabowski
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Michał
authors.initials: M
authors.lastname: Kartasiński
authors.affiliation: Intensive Care Unit of Mother Memorial Hospital Research Institute in Lodz, Rzgowska 281/289, Lodz, 93-338, Poland.
authors.forename: Wojciech
authors.initials: W
authors.lastname: Krajewski
authors.affiliation: Department of Forensic Medicine, Medical University of Lodz, Sedziowska 18a, Lodz, 91-304, Poland.
authors.forename: Jarosław
authors.initials: J
authors.lastname: Berent
mesh_terms: D000328:Adult; D000891:Anti-Infective Agents, Local / Q000009:adverse effects*; D002056:Burns / Q000209:etiology*; D004564:Electrocoagulation / Q000009:adverse effects*; D004630:Emergencies; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D019300:Medical Errors / Q000331:legislation & jurisprudence; D011044:Poland; D011782:Quadriplegia; D014135:Tracheal Stenosis / Q000209:etiology / Q000601:surgery; D014139:Tracheostomy / Q000009:adverse effects; D014140:Tracheotomy / Q000009:adverse effects*
chemical_list: D000891:Anti-Infective Agents, Local
keywords: burns; complications; electrocautery; forensic science; medical error; medical opinion; tracheotomy