[Undetected of Esophageal Intubation for Two Hours of Cardiopulmonary Resuscitation].

Securing of airway is one of the most important issues during cardiopulmonary resuscitation, and oro- tracheal intubation has been a gold standard proce- dure. We experienced a case in which the esophageal intubation was overlooked for 2 hours after the intuba- tion at the bedside of general ward and in the inten- sive care unit A 71-year-old male patient without marked medical history was transferred to our hospital with severe symptom of lower gastrointestinal ileus. After admitting to the ward, transrectal drainage tube was placed. On the night of the admission, the patient called the staff from his bed ; however, he lost con- sciousness and monitoring electrocardiogram showed sudden bradycardia followed by cardiac arrest Emer- gency cardiopulmonary resuscitation was initiated and the intubation was conducted by the physician on call. The cardiovascular status was unstable despite recov- ery of spontaneous circulation (ROSC) and the patient was transferred to the intensive care unit The arrest and ROSC by resuscitation was repeated. After 2 hours from the start of resuscitation, temporal ROSC was obtained, but the absence of a wave of capnogram was identified. The observation using laryngoscopy revealed esophageal intubation and oro-tracheal intuba- tion was facilitated. Although the mechanical ventila- tion was established, the condition of the patient dete- riorated with pulseless electrical activity followed by death.