Iatrogenic Burns of the Neckline in a Patient with Tetraparesis During Tracheotomy1. Issue 1 (10th November 2016)

• Record Type: Journal Article
• Authors: Smędra, Anna; Meissner, Ewa; Barzdo, Maciej; Grabowski, Przemysław; Kartasiński, Michał; Krajewski, Wojciech; Berent, Jarosław
• Is Part Of: Journal of forensic sciences. Volume 62:Issue 1(2017)
• Page Start: 250
• Page End: 253
• Publication Date: 2016-11-10
• Subjects: forensic science -- electrocautery -- tracheotomy -- complications -- burns -- medical error -- medical opinion; Medical jurisprudence -- Periodicals; Forensic sciences -- Periodicals; Forensic Medicine -- Periodicals; Gerechtelijke geneeskunde; Gerechtelijke chemie; Gerechtelijke psychiatrie; 363.2505
• DOI: 10.1111/1556-4029.13240
• Languages: English
• ISSNs: 0022-1198

Abstract

Abstract: The paper presents a case of an atypical iatrogenic complication after tracheotomy analyzed on the basis of the case dossier materials submitted to the authors by the court of justice to prepare a forensic medical opinion concerning the correctness of the medical procedure. A 37‐year‐old woman was brought by the ambulance service to the hospital with acute respiratory failure due to post‐tracheostomy tracheal stenosis. Tracheotomy was performed on an emergency basis. The patient suffered severe burns of the chest and neck. The experts concluded that the most probable cause of the incident was electrocautery‐induced ignition of the disinfectant used for cleaning the skin before the surgery. It was established that with correct handling of the procedure, the aforementioned incident should not have taken place. Therefore, it cannot be regarded as a normal complication inherent in the risk associated with the procedure, but as a consequence of a medical error.