It was reported that the patient expired after a malfunction of a portex® cuffed blue line ultra® tracheostomy tube.It was reported that the patient sustained a tracheal injury by "explosion" of the cuff.While attempting to perform a cannula replacement, "bulging" was observed and it was necessary to change the tracheostomy tube twice.It was observed that the patient experienced a tracheal lesion due to the cuff, followed by bilateral pneumothorax, hemodynamic instability, and cpr.Patient required cpr for 40 minutes and was moved to electrical cardioversion and prescribed amiodarone when patient went into ventricular fibrilation and tachycardia.Cpr was restarted and patient passed away 7 minutes later.
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