Laryngeal Tube False Intubation during Cardiopulmonary Resuscitation - a Case Report

The death of an 80-year-old female patient is described who suffered a fall-related thoracic contusion with rupture of an emphysema bulla during an inpatient stay. Due to the consecutive development of a tension pneumothorax, the patient required resuscitation immediately. During resuscitation an esophageal perforation was initially caused by the inserted laryngeal tube. After "correction" of this position, the laryngeal tube was found to be placed in the larynx at autopsy. Pleural decompression had not been performed despite the development of a massive tension pneumothorax with extensive soft tissue emphysema. This case once again emphasizes the need for a structured approach to airway management during cardiopulmonary resuscitation. With regard to current guidelines, the tension pneumothorax would have been addressed. The use of a supraglottic airway device (not otherwise used in everyday clinical practice) should be trained intensively or possibly even reconsidered.