Management of an unusual pediatric difficult airway using ketamine as a sole agent

Abstract

We present the case of a 9-year-old boy who suffered a fall while brushing his teeth. This resulted in impalement of the lateral pharyngeal wall by the toothbrush with its head becoming firmly lodged adjacent to the internal carotid artery as demonstrated by CT scan. The length of the toothbrush protruding from the mouth and the inability to adequately assess the airway prior to any intervention gave rise to a unique set of surgical and anesthetic airway management problems. These were compounded by the possibility of damage to the carotid artery and potential catastrophic hemorrhage with manipulation of the toothbrush at any point. We detail the problems and outline our management.

Is it safe to use a toothbrush?

“…There are a few case reports describing such injuries or accidents involving the ingestion or impalement of a toothbrush [7,8].…”

A case of unusual difficult airway because of an intracranial foreign body of bamboo chopstick

“…Intravenous access was established followed by the administration of ketamine 20 mg i.v. (1). The patient breathed spontaneously and required gentle chin lift and jaw thrust.…”

Sedation and anesthesia for fiberoptic intubation in management of pediatric difficult airways

“…These characteristics make it a reasonable choice for sedation of infants, young child, or mentally delayed older child or adolescent. It may be used alone (6) or in conjunction with midazolam (7) or dexmedetomidine. However, a careful titration of the dose is essential because ketamine has been documented to cause apnea in a healthy pediatric patient (8) and there are no reversal agents.…”

“…However, adequate ketamine or ketamine-midazolam dose combined with good suctioning and skilled endoscopy techniques are the best defense against airway reactivity. In fact, ketamine is a commonly described anesthetic agent for fiberoptic airway management in children with difficult airways and no problems with increased airway reactivity have been noted (6,7,9,10…”

“…We preferred intravenous anesthesia with fentanyl, ketamin and midazolam as i.v. anesthesia may offer hemodynamic stability in children with single ventricle CHD (6)(7)(8).…”