SummaryA case is reported in which a young man who required tracheal intubation and intermittent positive pressure ventilation for head and chest injuries, inhaled a foreign body after extubating himself. The unusual nature of theforeign body and the manner of its entering the tracheobronchial tree is reported. The case suggests that the practice of usingprotective rubber sleeves on the jaws of mouth gags be reviewed and highlights the need to inspect all instruments after use, particularly those that have been employed in the mouth and upper airways.
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