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, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute chang
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