Sex Disparities in Applied Force on Maxillary Incisors Among Novices During Laryngoscopy Using a High-Fidelity Simulator: A Prospective Observational Study.

Endotracheal intubation (ETI) is a common and crucial intervention. Whether the performance of ETI differs according to the sex of the laryngoscopist remains unclear. The aim of this study was to assess sex disparities in markers of ETI performance among novices using a high-fidelity simulator. This prospective observational study was conducted from April 2017 to March 2019 in a public medical university. In total, 209 medical students (4th and 5th grade) without clinical ETI experience were recruited. Of the 209 students, 64 (30.6%) were female. The participants used either a Macintosh direct laryngoscope or C-MAC video laryngoscope in combination with a stylet or gum-elastic bougie to perform ETI on a high-fidelity simulator. The primary endpoint was the maximum force applied on the maxillary incisors during laryngoscopy. The secondary endpoint was the time to ETI. The implanted sensors in the simulator automatically quantified the force and time to ETI. The maximum force applied on the maxillary incisors was approximately 30% lower in the male than female group for all laryngoscopes and intubation aids examined (all P < 0.001). Similarly, the time to ETI was approximately 10% faster in the male than female group regardless of the types of laryngoscopes and intubation aids used (all P < 0.05). In this study, male sex was associated with a lower maximum force applied on the maxillary incisors during both direct and indirect laryngoscopy performed by novices. A clinical study focusing on sex differences in ETI performance is needed to validate our findings.

Long-Term Incidence and Timing of Splenic Pseudoaneurysm Formation after Blunt Splenic Injury: A Descriptive Study.

BACKGROUND: Nonoperative management (NOM) has become a standard strategy for hemodynamically stable patients with blunt splenic injury; however, delayed rupture of splenic pseudoaneurysm (SPA) is a serious complication of NOM. In medical literature, data regarding the long-term incidence of SPA are scarce, and the appropriate timing for performing follow-up contrast-enhanced computed tomography (CT) has not yet been reported. This study aimed to elucidate the long-term incidence and timing of SPA formation after blunt splenic injury in patients treated with NOM. METHODS: This descriptive study was conducted at a tertiary medical center in Japan. Patients with blunt splenic injury who were treated with NOM between April 2014 and August 2020 were included in the analysis. Included patients underwent repeated contrast-enhanced CT to detect SPA formation. The primary outcome was the cumulative incidence of delayed formation of SPA. We also evaluated differences in SPA formation between patients who received transcatheter arterial embolization (TAE; TAE group) and those who did not receive it (non-TAE group) on admission day. RESULTS: Among 49 patients with blunt splenic injury who were treated with NOM, 5 patients (10.2%) had delayed formation of SPA. All cases of SPA formation occurred within 15 days of injury. The incidence of SPA formation was not significantly different between the TAE and non-TAE groups (1/19 vs. 4/30, P = 0.67). CONCLUSIONS: SPA developed in 10% of patients within approximately 2 weeks after blunt splenic injury. Therefore, performing follow-up contrast-enhanced CT in this period after injury may be useful to evaluate delayed formation of SPA. Although our findings are novel, they should be confirmed through future studies with larger sample sizes.

Transcatheter arterial embolization using imipenem/cilastatin sodium and microspheres for traumatic pseudoaneurysm: A case report.

For transcatheter arterial embolization (TAE) of pseudoaneurysms, when the culprit artery is too small or tortuous to be selected with a microcatheter, n-butyl-2-cyanoacrylate (NBCA) may be used as embolic material. Nevertheless, NBCA can cause inadvertent embolization and ischemic complications because liquid adhesives cannot be controlled precisely. In such cases, imipenem/cilastatin sodium (IPM/CS) could be used as an alternative to NBCA for TAE. However, TAE using IPM/CS for traumatic pseudoaneurysms has not been reported previously. Therefore, the possibility of using IPM/CS to embolize refractory traumatic pseudoaneurysms with small culprit arteries remains unknown. A previously healthy 51-year-old man sustained multiple traumatic injuries, including an open pelvic fracture. An emergency TAE for the pelvic fracture, massive blood transfusion, and emergency colostomy and cystostomy were performed on admission day, following which the patient was hemodynamically stable. However, he had repeated episodes of hematochezia due to pelvic pseudoaneurysm on days 18, 53, 60, and 70 after admission despite several TAE attempts using gelatin sponge, coils, and NBCA. During recurrence on day 70, we performed TAE using IPM/CS and microspheres, following which the pseudoaneurysm resolved without rebleeding or obvious ischemic complications. IPM/CS and microspheres could embolize, without rebleeding, the refractory pseudoaneurysm in small and tortuous culprit arteries that could not be embolized with NBCA. For embolization of traumatic pseudoaneurysms with severe tissue damage and small culprit arteries, NBCA might not be able to reach the bleeding point. In such cases, TAE using IPM/CS and microspheres could be a safe and effective procedure.

Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan.

Injured patients requiring definitive intervention, such as surgery or transarterial embolization (TAE), are an extremely time-sensitive population. The effect of an emergency physician (EP) patient care delivery system in this important trauma subset remains unclear. We aimed to clarify whether the preoperative time course and mortality among injured patients differ between ambulances staffed by EPs and those staffed by emergency life-saving technicians (ELST). This was a retrospective cohort study at a community emergency department (ED) in Japan. We included all injured patients requiring emergency surgery or TAE who were transported directly from the ED to the operating room from January 2002 to December 2019. The primary exposure was dispatch of an EP-staffed ambulance to the prehospital scene. The primary outcome measures were preoperative time course including prehospital length of stay (LOS), ED LOS, and total time to definitive intervention. The other outcome of interest was in-hospital mortality. One-to-one propensity score matching was performed to compare these outcomes between the groups. Of the 1,020 eligible patients, 353 (34.6%) were transported to the ED by an EP-staffed ambulance. In the propensity score-matched analysis with 295 pairs, the EP group showed a significant increase in median prehospital LOS (71.0 min vs. 41.0 min, P < 0.001) and total time to definitive intervention (189.0 min vs. 177.0 min, P = 0.002) in comparison with the ELST group. Conversely, ED LOS was significantly shorter in the EP group than in the ELST group (120.0 min vs. 131.0 min, P = 0.043). There was no significant difference in mortality between the two groups (8.8% vs.9.8%, P = 0.671). At a community hospital in Japan, EP-staffed ambulances were found to be associated with prolonged prehospital time, delay in definitive treatment, and did not improve survival among injured patients needing definitive hemostatic procedures compared with ELST-staffed ambulances.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan.

ABSTRACT: Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

Intraoperative fluid management in hepato-biliary-pancreatic operation using stroke volume variation monitoring: A single-center, open-label, randomized pilot study.

TRIAL DESIGN: This investigator-initiated, single-center, open-label, parallel-group, randomized-controlled pilot study was designed to compare the intraoperative fluid balance and perioperative complications in patients undergoing hepato-biliary-pancreatic surgery with or without stroke volume variation (SVV)-guided fluid management. METHODS: Patients who were aged >18 years and underwent elective major hepato-biliary-pancreatic surgery between June 30, 2015, and August 31, 2016 at our center were randomly assigned to receive SVV-guided or conventional fluid therapy. The intervention group used SVV to determine the patients' volume status. The primary outcome was the total fluid balance per body weight per operation time, and the secondary outcomes were the total amount of intravenous infusion per body weight per operation time and the Sequential Organ Failure Assessment score on postoperative day 1. Patients were randomized by a two-block computer-generated assignment sequence. Masking of patients and assessors was conducted. The patients and assessors were each blinded to the details of the trial; however, the clinicians were not. RESULTS: Of the 69 patients who were initially eligible, 60 provided informed consent for participation in the study. After randomization, three patients dropped out of the study because of deviations from the protocol or unexpected hypotension, leaving 28 and 29 patients in the intervention and control groups, respectively. Patients in both groups had similar characteristics at baseline. The median (interquartile range [IQR]) intraoperative fluid balance in the control and SVV groups was 6.2 (IQR, 4.9-7.9) and 8.1 (IQR, 5.7-10.5) ml/kg/h, respectively (P = .103). The administered intravenous infusion was significantly higher in the SVV group (median, 10.9; IQR, 8.3-15.3 ml/kg/h) than in the control group (median, 9.5; IQR, 7.7-10.3 ml/kg/h) (P = .011). On postoperative day 1, the PaO2/FiO2 ratio was lower in the SVV group (median, 266; IQR, 261-341) than in the control group (median, 346; IQR, 299-380) (P = .019). CONCLUSIONS: Use of the SVV-guided fluid management protocol did not reduce intraoperative fluid balance but increased the intraoperative fluid administration and might worsen postoperative oxygenation. TRIAL REGISTRATION: UMIN000018111.

The use of veno-venous extracorporeal membrane oxygenation for massive hemoptysis following a traumatic lung injury: a case report.

BACKGROUND: Published reports regarding the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) for massive hemoptysis following a thoracic injury are still scarce. CASE PRESENTATION: A 34-year-old man developed massive hemoptysis from the right lung after a 2 m fall and being compressed with an iron pipe weighing 500 kg. He was immediately intubated using a double-lumen tube, and one-lung ventilation was started. Endotracheal hemorrhage was controlled by sealing the right lumen. V-V ECMO was initiated to endure the lethal hypoxemia while waiting for the right lung to heal. He came off of V-V ECMO after 17 days and was discharged on foot on day 46. CONCLUSION: The strategy of using V-V ECMO in combination with one-lung ventilation is useful and should be strongly considered to save lethal massive hemoptysis cases following traumatic lung injury.

Lower maximum forces on oral structures when using gum-elastic bougie than when using endotracheal tube and stylet during both direct and indirect laryngoscopy by novices: a crossover study using a high-fidelity simulator.

BACKGROUND: Applying excessive force during endotracheal intubation (ETI) is associated with several complications, including dental trauma and hemodynamic alterations. A gum-elastic bougie (GEB), a type of tracheal tube introducer, is a useful airway adjunct for patients with poor laryngoscopic views. However, how the use of a GEB affects the force applied during laryngoscopy is unclear. We compared the force applied on the oral structures during ETI performed by novices using the GEB versus an endotracheal tube + stylet. METHODS: This prospective crossover study was conducted from April 2017 to March 2019 in a public medical university in Japan. In total, 209 medical students (4th and 5th grade, mean age of 23.7 ± 2.0 years) without clinical ETI experience were recruited. The participants used either a Macintosh direct laryngoscope (DL) or C-MAC video laryngoscope (VL) in combination with a GEB or stylet to perform ETI on a high-fidelity airway management simulator. The order of the first ETI method was randomized to minimize the learning curve effect. The outcomes of interest were the maximum forces applied on the maxillary incisors and tongue during laryngoscopy. The implanted sensors in the simulator quantified these forces automatically. RESULTS: The maximum force applied on the maxillary incisors was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (39.0 ± 23.3 vs. 47.4 ± 32.6 N, P < 0.001) and C-MAC VL (38.9 ± 18.6 vs. 42.0 ± 22.1 N, P < 0.001). Similarly, the force applied on the tongue was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (31.9 ± 20.8 vs. 37.8 ± 22.2 N, P < 0.001) and C-MAC VL (35.2 ± 17.5 vs. 38.4 ± 17.5 N, P < 0.001). CONCLUSIONS: Compared with the use of an endotracheal tube + stylet, the use of a GEB was associated with lower maximum forces on the oral structures during both direct and indirect laryngoscopy performed by novices. Our results suggest the expanded role of a GEB beyond an airway adjunct for difficult airways.

Impact of the academic calendar cycle on survival outcome of injured patients: a retrospective cohort study at a community emergency department in Japan.

BACKGROUND: Commencement of a new academic cycle is presumed to be associated with poor patient outcomes. However, supportive evidence is limited for trauma patients treated in under-resourced hospitals, especially those who require specialized interventions and with little physiological reserve. We examined whether a new academic cycle affects the survival outcomes of injured patients in a typical Japanese teaching hospital. METHODS: This historical cohort study was conducted at a Japanese community emergency department (ED). All injured patients brought to the ED from April 2002 to March 2018 were included in the analysis. The primary exposure was presentation to the ED during the first quartile of the academic cycle (April-June). The primary outcome measure was the hospital mortality rate. RESULTS: Of the 20,945 eligible patients, 5282 (25.2%) were admitted during the first quartile. In the univariable analysis, the hospital mortality rate was similar between patients admitted during the first quartile of the academic year and those admitted during the remaining quartiles (4.1% vs. 4.4%, respectively; odds ratio [OR], 0.931; 95% confidence interval [CI] 0.796-1.088). After adjusting for the potential confounding factors of the injury severity score, age, sex, Glasgow coma scale score, systolic blood pressure, trauma etiology (blunt or penetrating), and admission phase (2002-2005, 2006-2009, 2010-2013, and 2014-2018), no statistically significant association was present between first-quartile admission and trauma death (adjusted OR 0.980; 95% CI 0.748-1.284). Likewise, when patients were subgrouped according to age of > 55 years, injury severity score of > 15, Glasgow coma scale score of < 9, systolic blood pressure of < 90 mmHg, requirement for doctor car system dispatches, emergency operation, emergency endotracheal intubation, and weekend and night presentation, no significant associations were present between first-quartile admission and hospital mortality in both the univariable and multivariable analysis. CONCLUSIONS: At a community hospital in Japan, admission at the beginning of the academic year was not associated with an increased risk of hospital mortality among trauma patients, even those requiring specialized interventions and with little physiological reserve. Our results support the uniformity of trauma care provision throughout the academic cycle in a typical Japanese trauma system.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature.

BACKGROUND: Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. CASE PRESENTATION: A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. CONCLUSIONS: In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Bacterial Meningitis Caused by Hypervirulent Klebsiella pneumoniae Capsular Genotype K54 with Development of Granuloma-like Nodal Enhancement in the Brain during the Subacute Phase.

A 72-year-old man was admitted to the emergency department due to coma. The cerebrospinal fluid cell count was 40,080 cells/µL, and Klebsiella pneumoniae was detected on culture. Stretching the bacterial colonies on an agar plate showed the formation of a viscous string with a length exceeding 5 mm, indicating hypervirulent K. pneumoniae (hv-KP). A genome analysis suggested hv-KP capsular genotype K54 with sequence type 29. Although no brain abscess was detected on contrast-enhanced computed tomography on Day 4 or on magnetic resonance imaging (MRI) on Day 7, contrast-enhanced MRI on Day 23 showed granuloma-like nodal enhancement on the surface of the left insula. Antibacterial therapy was continued until the enhancement disappeared on Day 40. MRI may help determine the duration required for antibacterial therapy. After six months, the patient was discharged and remained free from recurrence.

Airway management in a patient with nuchal, interspinous, and flavum ligament rupture by a sickle: a case report.

BACKGROUND: Penetrating neck injury is an important trauma subset but is relatively rare, especially when involving the posterior cervical column. Rupture of the neck restraints, including the interspinous and flavum ligaments, can create serious cervical instability that requires special consideration when managing the airway. However, no detailed information regarding airway management in patients with profound posterior neck muscle laceration and direct cervical ligament disruption by an edged weapon is yet available in the literature. CASE PRESENTATION: A 63-year-old Japanese man attempted to cut off his head using a sickle after drinking a copious amount of alcohol. On admission, his posterior vertebral column was grossly exposed and the lacerated tissues were actively bleeding, resulting in severe hypovolemic shock. We used a rapid-sequence intubation technique with direct laryngoscopy while manual in-line stabilization of his head and neck was maintained by several people. Surgical exploration revealed nuchal, interspinous, and flavum ligament rupture between his fourth and fifth cervical vertebrae, but no injury to the great vessels was present. The major source of bleeding was a site of oozing from his trapezius and splenius muscles. After surgical hemostasis, wound repair, and subsequent intensive care, our patient was discharged home without any neurological sequelae. CONCLUSIONS: Deficits of the neck restraints can cause cervical spine subluxation and dislocation secondary to neck movement. Thus, the key to successful airway management in such a scenario is minimization of neck movement to prevent further neurological impairment. We successfully managed an airway using a conventional but trusted endotracheal intubation strategy in a patient with multiple traumas and a suspected spinal cord injury. This case also illustrates that, even when great vessel injury is absent, severe hypovolemic shock may occur after profound neck muscle laceration, requiring immediate surgical intervention.

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study.

BACKGROUND: Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours. METHODS: This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002-2005, 2006-2009, and 2010-2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models. RESULTS: Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1-2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours. CONCLUSIONS: At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.

Emergency endotracheal intubation-related adverse events in bronchial asthma exacerbation: can anesthesiologists attenuate the risk?

PURPOSE: Airway management in severe bronchial asthma exacerbation (BAE) carries very high risk and should be performed by experienced providers. However, no objective data are available on the association between the laryngoscopist's specialty and endotracheal intubation (ETI)-related adverse events in patients with severe bronchial asthma. In this paper, we compare emergency ETI-related adverse events in patients with severe BAE between anesthesiologists and other specialists. METHODS: This historical cohort study was conducted at a Japanese teaching hospital. We analyzed all BAE patients who underwent ETI in our emergency department from January 2002 to January 2014. Primary exposure was the specialty of the first laryngoscopist (anesthesiologist vs. other specialist). The primary outcome measure was the occurrence of an ETI-related adverse event, including severe bronchospasm after laryngoscopy, hypoxemia, regurgitation, unrecognized esophageal intubation, and ventricular tachycardia. RESULTS: Of 39 patients, 21 (53.8 %) were intubated by an anesthesiologist and 18 (46.2 %) by other specialists. Crude analysis revealed that ETI performed by an anesthesiologist was significantly associated with attenuated risk of ETI-related adverse events [odds ratio (OR) 0.090, 95 % confidence interval (CI) 0.020-0.41, p = 0.001]. The benefit of attenuated risk remained significant after adjusting for potential confounders, including Glasgow Coma Score, age, and use of a neuromuscular blocking agent (OR 0.058, 95 % CI 0.010-0.35, p = 0.0020). CONCLUSIONS: Anesthesiologist as first exposure was independently associated with attenuated risk of ETI-related adverse events in patients with severe BAE. The skill and knowledge of anesthesiologists should be applied to high-risk airway management whenever possible.

Massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum after multiple direct laryngoscopies: an autopsy case report.

Multiple endotracheal intubation (ETI) attempts increase the risk of airway-related adverse events. However, little is known about autopsy findings after severe ETI-related complications. We present the detailed pathological findings in a patient with severe ETI-related complications. A 77-year-old obese male suffered cardiopulmonary arrest after choking at a rehabilitation facility. Spontaneous circulation returned after chest compressions and foreign-body removal. After multiple failed direct laryngoscopies, the patient was transferred to our hospital. He had massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum on admission, and died from hypoxic brain injury 15 h later. Autopsy revealed severe oropharyngeal, laryngeal, and left lung lower lobe injury. The likely mechanisms of diffuse emphysema were (1) oropharyngeal injury associated with multiple ETI attempts and excessive ventilation pressures and (2) left lung lower lobe injury associated with chest compressions and other resuscitative procedures. Multiple laryngoscopies can cause severe upper-airway injury, worsen respiratory status, and make ETI more difficult-a vicious circle that can be prevented by limiting ETI attempts. This is particularly important in unfavorable environments, in which backup devices and personnel are not easily obtained. The pathological findings in our patient caution against repeated attempts at ETI during resuscitation.