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January 20, 1975

Death Precipitated by Tracheostomy in a Child

Author Affiliations

From the Department of Anesthesiology, The Abraham Lincoln School of Medicine, University of Illinois College of Medicine, Chicago (Drs. Schmidt and Bennett), and the Department of Anesthesiology, Loyola University Stritch School of Medicine, Maywood, III (Dr. Dalal).

JAMA. 1975;231(3):277-278. doi:10.1001/jama.1975.03240150039020

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;