![]() The case was referred to me for postmortem analysis. The patient’s family declined to have an autopsy performed. These findings were independently confirmed by the head and neck surgeon who assisted at the patient’s resuscitation. Moreover, the cuff of the endotracheal tube was noted to be inflated within the lumen of the esophagus. The patient’s esophagus was visualized, as were the rugae of his stomach. He passed a fiberoptic bronchoscope through the endotracheal tube. The patient could not be resuscitated and was pronounced dead after 45 min of advanced life support, after which the department chairman reviewed the case. An ear, nose, and throat surgeon, called in to assist with resuscitation, listened to the breath sounds and concluded that the endotracheal tube was in the trachea. Next, the patient had a cardiac arrest and advanced cardiac life support was begun. Atropine 1 mg and then epinephrine 1 mg were administered. Despite the above measures, the patient’s oxygenation continued to decline and he became bradycardic. A diagnosis of bronchospasm was made and the patient was administered isoflurane 5% and albuterol via the endotracheal tube. The patient was difficult to ventilate, with peak airway pressures exceeding 40 mm Hg. During this period, approximately 10 carbon dioxide square waves were observed. Over the ensuing minute, the patient’s oxygen saturation declined from 93% to 82% and the end-tidal carbon dioxide decreased to 10 mm Hg. Breath sounds were distant after the second intubation. From the time of the esophageal extubation until the next intubation, the patient was not ventilated by mask. After placement of the endotracheal tube, an end-tidal carbon dioxide recording of 35 mm Hg, with a normal square wave tracing was observed on the Datex monitor (Datex, Helsinki, Finland). Finally, a third direct laryngoscopy was performed by the attending with visualization of the vocal cords. Immediately, a second laryngoscopy, which resulted in a grade IV view, was performed by the attending anesthesiologist. The first attempt at intubation by a nurse anesthetist resulted in an esophageal intubation, which was recognized by the absence of end-tidal carbon dioxide. Fentanyl 100 μg, propofol 200 mg, and succinylcholine 100 mg were then administered in rapid sequence. In the operating room he was denitrogenated with 100% oxygen for 3 min. ![]() He took Prilosec (AstraZeneca, Wayne, PA), verapamil, and Prozac (Eli Lilly, Indianapolis, IN) daily, including the morning of surgery, with a sip of water.īefore the induction of anesthesia, the patient was administered 30 mL Bicitra (Alza Pharmaceuticals, San Bruno, CA) by mouth and metoclopramide 10 mg IV in the holding area. Lung fields were distant but clear to auscultation, and his heart sounds were regular and without murmur. Examination before anesthesia showed adequate neck extension and a Mallampati class II airway. His surgical history included three knee arthroscopies and a left nephrectomy. His medical history included depression, coronary artery disease, hypertension, hiatal hernia, and gastric reflux. The patient was a morbidly obese male (143 kg, 170 cm in height) who was scheduled for knee arthroscopy. The importance of having fiberoptic bronchoscopy immediately available is also stressed. A possible source of this anomalous carbon dioxide is discussed and the physiological conditions producing this condition in an artificial stomach are described. This case was notable for a normal end-tidal carbon dioxide tracing after intubation. I present the case of a 52-yr-old man who likely died from an unrecognized esophageal intubation after the induction of general anesthesia. ![]()
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