Case by Mickey Emmanuel, CNH PEM Fellow

A 3-year-old boy with no significant past medical history comes to the ED today with a toothbrush impaled in the oropharynx.

Mom did not witness the event but did note that he was jumping up and down on the bed while brushing his teeth.  She believes he fell and the toothbrush itself became stuck in the back left corner of his mouth.  He originally tried to pull it out but started producing some blood from his mouth.  She states the toothbrush was firmly lodged and unable to move in any direction. No apparent dental trauma or respiratory distress. He is drooling slightly but is largely able to maintain secretions and is swallowing without difficulty. No vomiting or continued bleeding from the oropharynx.  No fevers or URI symptoms.

ROS: Otherwise negative
PMH: Otherwise healthy (no asthma)
PSH: None
Vaccinations: UTD
Medications: None

VS: T: 37C, HR 125: RR: 25  BP: 110/70  O2: 98% on RA

Physical Examination
General:  Alert.  appropriate for age.  Anxious and thrashing when examined but consolable in mother’s arms.
Skin:  Warm.  dry.  pink. 
Head:  Normocephalic.  atraumatic.  
Neck:  Supple
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  
Ears, nose, mouth and throat:  Oral mucosa moist.  Unable to have patient comply with opening mouth fully (due to fussiness and pain from impaled foreign body), no overt bleeding appreciated from the oropharynx, anterior teeth intact, maintaining secretions. Externally on the L side of face, can appreciate mass/bulging on the posterior aspect of the mandible at the junction of the angle of the mandible and neck.
Cardiovascular:  Regular rate and rhythm.  No murmur.  No gallop.  
Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  No stridor.  
Gastrointestinal:  Soft.  Nontender.  Non-distended.  
Musculoskeletal:  Normal ROM.  Moving all extremities.
Neurological:  Alert.  No focal neurological deficit observed.

You page ENT stat and also decide that you need imaging of the Neck (CTA) to ensure no penetrating trauma leading to vascular injury prior to removal in the OR. Given persistent fussiness and need for IV placement for contrast you administer IN fentanyl prior to placement of IV. IV was placed and the patient was still persistently fussy and thrashing. Given patient is unlikely to tolerate imaging without further sedation, you pursue thoughts of additional sedation for imaging:

Click here for the case conclusion