This week we highlight the case of a child who had a toothbrush impaled in the oropharynx. The crux of the decision centered around sedation for imaging with a potentially unstable oropharyngeal injury. It is important to note that though the patient was currently stable in this case, he had a high potential to be a difficult away. Caution should be made when bagging the patient as that could further dislodge the impaled toothbrush and worsen any underlying injury.

If possible, all agreed that avoiding sedation in this case was preferable. If you are able to obtain a good physical exam and can confidently state the toothbrush is impaled more laterally, then imaging to rule out vascular injury is not necessary. According to a systematic review by Curry et.al, “Routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes. Given the poor physical exam in this case due to patient intolerance, ENT recommended further imaging.

For sedative agents, junior learners preferred midazolam while senior learners preferred ketamine. The proposed benefit of midazolam was that it avoids the potential side effects of laryngospasm and increased secretions. Most agree that another ideal alternative would be propofol given its rapid onset and half-life. Most respondents wanted ENT or anesthesia at the bedside to sedate given the potential high risk.

In this case, Anesthesia was consulted given the challenging airway with an impaled foreign body in the oropharynx. They recommend ketamine for sedation for imaging. Per anesthesia consult; they recommend ketamine (10 mg first, then 5 mg x2 to for imaging to titrate to dissociation; patient is 17 kg; ~ 1.5mg/kg). Anesthesia was unable to be present during the sedation when asked but provided a phone number in case of escalation. Ultimately, sedation with ketamine was performed in the Radiology suite with Vital sign monitoring, EtCO2, suction, Self-inflating mask and oxygen present if necessary. An escalation plan was discussed with the charge nurse, charge doc and anesthesia prior to transfer to CT for sedation.

The patient tolerated the procedure well without any complications. CT showed an impaled foreign body entering the left posterior aspect of the mouth, penetrating buccal mucosa, traversing buccal space, and terminating in the left parotid gland. The foreign body was removed in the OR without complications with ENT.