Anesthesiology, V 120 • No 2 480 February 2014 A 5.6-KG term neonate was born via spontane- ous vaginal delivery compli- cated by shoulder dystocia; Apgar scores were 5 and 7 at 1 and 5 min. e neonate received continuous positive airway pressure for respira- tory distress, developed cervi- cal emphysema, and then was intubated because of hypox- emia. Although capnogra- phy appeared to indicate a successful intubation, breath sounds were undetectable by auscultation. Chest tubes were placed after a radiograph showed bilateral pneumothoraces. e neonate arrived at our institution in extremis (heart rate, 59 beats/min; mean arterial pressure, 50 mmHg; SpO 2 , 62%). Venoarterial extracorporeal membrane oxygenation was initiated via the right internal jugular vein and the right internal carotid artery. Computed tomography showed absent lung aeration, the arterial cannula (fig. 1A, ac), subcutaneous emphy- sema (fig. 1A, white arrows), and the endotracheal tube diverging from the midline (fig. 1A, black arrows). Bronchoscopy by the otorhinolaryngologist confirmed a laryngeal tear with a ruptured anterior commissure (fig. 1B, asterisks) through which the endotracheal tube traveled into the mediastinum. e otorhinolaryngologist repositioned the endotracheal tube into the native trachea (fig. 1B). Support was withdrawn 6 days later after progression of hypoxic ischemic injury. Autopsy findings included a hypoplastic thyroid cartilage that likely resulted in an inherent weakness of the anterior tracheal wall. Traumatic delivery and endotracheal intubation can cause life-threatening tracheal and laryngeal injuries in neonates. 1 Develop- ment of cervical emphysema before intubation suggests that this child’s laryngeal rupture was caused by a difficult delivery rather than traumatic intubation. Fiberoptic endoscopy should be used to investigate potential airway rupture, with emergent otorhinolar- yngology consultation and deferral of endotracheal intubation until direct airway visualization has been accomplished. 2 Extracorpo- real membrane oxygenation should be considered early if direct airway visualization cannot be performed. 3 Competing Interests The authors declare no competing interests. Correspondence Address correspondence to Dr. Simpao: simpaoa@email.chop.edu References 1. Mahieu HF, de Bree R, Ekkelkamp S, Sibarani-Ponsen RD, Haasnoot K: Tracheal and laryngeal rupture in neonates: Complication of delivery or of intubation? Ann Otol Rhinol Laryngol 2004; 113:786–92 2. Kacmarynski DS, Sidman JD, Rimell FL, Hustead VA: Spontaneous tracheal and subglottic tears in neonates. Laryngoscope 2002; 112(8 Pt 1):1387–93 3. Kunisaki SM, Fauza DO, Craig N, Jennings RW: Extracorporeal membrane oxygenation as a bridge to definitive tracheal reconstruc- tion in neonates. J Pediatr Surg 2008; 43:800–4 From the Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, and The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (A.F.S.). Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:480 Charles D. Collard, M.D., Editor Alan Jay Schwartz, M.D., M.S. Ed., Associate Editor Shoulder Dystocia, Laryngeal Tear, Mediastinal Intubation, and Extracorporeal Membrane Oxygenation in a Neonate Allan F. Simpao, M.D., Luv R. Javia, M.D., Alan Jay Schwartz, M.D., M.S.Ed., Mohamed A. Rehman, M.D. IMAGES IN ANESTHESIOLOGY Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/930985/ on 11/13/2018