The Lost Endotracheal Tube - A Rare Complication of Accidental Esophageal Intubation

Endotracheal intubation is a discreet skill for the management of compromised airway. Various complications associated with this procedure have been described. Here, we would like to present a pediatric patient suffering from cerebellar atrophy, who was intubated in a local clinic due to seizure with cyanosis and loss of consciousness. Unfortunately, due to inadvertent esophageal intubation and bad management, the patient swallowed the endotracheal tube together with two detached loose teeth. This irrational and iatrogenic medical misconduct as exemplified in this accident calls forth the need of educating and disciplining the nonanesthetic physicians for acute management of airway, particularly of those who would likely come across difficult airway problems.

關鍵字

Intubation: endotracheal ； Complication: esophageal intubation

並列摘要

氣管插管是處理呼吸道阻塞或呼吸衰竭的一種重要救命技術。執行過程中所造成的組織傷害、吸入性肺炎、內管異位等併發症已有許多報告。本病例報告是一位小腦萎縮的小兒病患，在癲癇發作時，因呼吸衰竭而接受氣管插管，造成口腔組織傷害及吞入氣管內管和牙齒的併發症。因為麻醉科醫師常被要求至急診室或病房處理呼吸道的問題，且急救插管並不總是那麼簡單，所以提出此病例的處理經驗和大家分享。

並列關鍵字

插管：氣管內管；併發症：食道插管

國際替代計量

The Lost Endotracheal Tube - A Rare Complication of Accidental Esophageal Intubation

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