THE death of an infant following tracheostomy illustrates the hazard of this procedure, especially in infants with poor lung compliance and pneumomediastinum.
Report of a Case
A 12-month-old boy was brought to the emergency room after having been found nearly drowned in a mop bucket containing detergent and dirty water. He had had no previous illness or hospitalizations and there was no history of any respiratory problems. He had moderate respiratory distress with intercostal and sternal retractions, and nasal flaring. Pulse rate was 180 beats per minute; respiratory rate, 70/min; and temperature, 39 C (102.2 F). Pieces of mop and dried detergent were noticed in his hair. Loud rhonchi with coarse and fine rales were heard throughout the lungs. Laboratory values were determined as follows: hematocrit, 27%; hemoglobin, 8.5 gm/100 ml; white blood cell count, 20,200/cu mm (polymorphonuclear leukocytes, 57%; stab cells, 30%; lymphocytes, 10%; monocytes, 3%); Na+, 142 mEq/liter;
Schmidt GB, Bennett EJ, Dalal FY. Death Precipitated by Tracheostomy in a Child. JAMA. 1975;231(3):277-278. doi:10.1001/jama.1975.03240150039020