DeathBTR
XOMED HUNSAKER MON-JET VENTILATION TUBE
Received Dec 18, 1997 · Event occurred Dec 10, 1997
Report 138952 · MDR key 138952
Product problems
- Unknown (for use when the device problem is not known)
Patient
38 YR
- Death
- Pneumothorax
Narrative
Description of Event or Problem
PT WAS TAKEN TO THE OPERATING ROOM FOR LARYNGOSCOPY WITH BIOPSY AND CULTURES DUE TO TRACHEAL STENOSIS. HUNSAKER TRACHEAL TUBE WAS PLACED AND ATTACHED TO JET VENTILATOR. APPROXIMATELY 3-6 PUFFS OF OXYGEN AT 52 PSI WERE ADMINISTERED WHEN THE NECK WAS NOTED TO SWELL AND THE FACE TURNED BLUE. BILATERAL PNEUMOTHORACES WERE RELIEVED WITH NEEDLE AND CHEST TUBE PLACEMENT. THERE WAS DIFFICULTY IN VENTILATING THE PT AND HE HAD A CARDIAC ARREST. EMERGENCY THORACOTOMY WAS PERFORMED AND PT WAS PLACED ON BYPASS. NO PERFORATION OR TEAR WAS EVIDENT. DESPITE PROLONGED RESUSCITATION EFFORTS, PT DIED.