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Accidental oxygen disconnection in the emergency department

Keywords: Airway management , bag-valve mask , breathing , hypoxia , intubation , oxygen , safety , training

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Abstract:

Accidental oxygen disconnection during rapid sequence intubation (RSI) in the emergency department is a potentially catastrophic yet avoidable event. We report three cases of inadvertent oxygen disconnection during RSI, which resulted in significant oxygen desaturation. This error can potentially be prevented by thorough preparation, focusing on teamwork training, ensuring an ergonomic environment, and by making simple modifications to existing equipment.

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