Abstract
A tracheostomal epithesis is a plastic prosthesis that serves for sealing a tracheostoma and ensuring the position of the tracheostomy tube. The production of a tracheostomal epithesis requires an impression of the tracheostoma. To this end, silicone impression material is applied by an anaplastologist in and around the tracheostomal region, including the trachea. The blocked cuff of the tracheostomy tube serves to prevent aspiration of the material. We report on a 13-year-old boy who died during this procedure because the lower airways were obstructed with cured silicone. Forensic autopsy confirmed asphyctic suffocation as cause of death. Forensic physical investigation of the tracheostomy tube and its cuff revealed no structural or functional defects. Yet, the investigation results prove that the viscous silicone must have passed the cuff. To conclude, this case report demonstrates that the production of an impression of a tracheostoma is a procedure with a potentially lethal outcome. Hence, professional guidelines, including clear safety precautions, are urgently needed.
Highlights
Tracheostomy represents one of the oldest and most frequently performed surgical procedures in critically ill adults and children [1]
If surgical modification failed or should be avoided, the irregularly formed tracheostoma can be corrected by insertion of an individually adjusted tracheostomal epithesis to seal the gap between the tracheostomy tube and tracheostoma
We report on the case of a child who died during this procedure due to airway obstruction with silicone impression material
Summary
Tracheostomy represents one of the oldest and most frequently performed surgical procedures in critically ill adults and children [1]. In the case of the tracheostomal epithesis, this device has functional significance as well: sealing the tracheostoma and ensuring the position of the tracheostomy tube. We report on the case of a child who died during this procedure due to airway obstruction with silicone impression material.
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have