Fatal iatrogenous neonatal massive air embolism with diffuse emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum.

Purpose: Fatal neonatal pneumothorax is often described in the literature as a consequence of prematurity and respiratory distress syndrome, pulmonary congenital anomalies, artificial ventilation and cardiopulmonary resuscitation.

Methods: Forensically clinical commentaries of the letal complications in perinatal malpractices.

Results: After an orderly term delivery in a 31.- year old tercipara, the newborn developed a clinical sign of meconium aspiration syndrome, for which he was primarily resuscitated with an APGAR score of 3,5,6. In the neonatology department, one hour after delivery, severe generalized emphysema and massive air embolism developed with bilateral pneumothorax, pneumomediastinum, pneumopericardium and pneumoperitoneum, as well as cardiac arrest and death. A direct connection between the oxygen supply pipe and the endotracheal tube was found with the consequent continuous overpressure and hyperoxygenation as the cause of the above pathological conditions, which were confirmed by autopsy with a massive air embolism.

Conclusion: For a forensic-clinical discussion, I consider this rare presentation of a massive lethal air plurifocal embolism to be a necessary contribution to the understanding of professional, educational and organizational communication failure. Alveolar overdistension with hyperinflation of oxygen led to imposibility of spontaneous and assisted ventilation, massive air embolism and consequent complications that led to death without response to resuscitation measures.