Right trace wrong place: a normal capnography trace despite the tip of the tracheal tube existing outside the airway

Abstract

SummaryHead and neck trauma can result in difficult airway management. A 25‐year‐old male required emergency tracheal intubation on arrival to the emergency department following a motorbike accident. Despite the presence of a normal capnography a computed tomography scan demonstrated a tracheal opening, an extra‐tracheal position of the distal end of the tracheal tube, and extensive subcutaneous emphysema. The tube was re‐directed into the trachea and the tracheal injury was surgically repaired. This case highlights that the presence of a normal capnograph does not necessarily mean that the distal end of the tracheal tube resides within the airway.