Cardiac arrest due to an unexpected inability to ventilate in a tracheostomy patient suggesting the need for a routine anesthesia checklist and an anesthesia relevant emergency pathway for tracheostomy management: a case report.

Background: Up to 30% of patients worldwide have a significant complication related to their tracheostomy. We report a case of a 'cannot ventilate' event resulting in cardiac arrest due to an unexpected airway occlusion in a patient with a pre-existing brain injury The following case report is unique as the patient had developed a mucus plug that turned into a crystal following a coronavirus disease 19 (COVID-19) infection.

Case Description: The patient was a young adult who suffered a traumatic brain injury from a motor vehicle collision.