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After a period of stability, trauma patients can unexpectedly deteriorate. If this happens it is important to follow a systematic approach, if necessary repeating the primary survey. The following is an unusual case of airway obstruction not previously reported in the literature.
An 11 year old boy was admitted to the emergency department after a fall of approximately 30 feet from the roof of a factory. His initial Glasgow Coma Scale was 7 at the scene and had fallen to 6 by the time of his arrival at hospital. He was intubated with a size 6.5 cuffed endotracheal tube (18 cm at the lips). Chest, pelvis, and C-spine radiographs were taken as part of the primary survey. These showed correct position of nasogastric and endotracheal tubes, no bony injuries, and no foreign bodies. The secondary survey revealed a Smith's fracture of the left forearm and minor cuts and bruises across his face. Urgent computed tomography of the head was performed. This showed cerebral oedema, a right petrous bone fracture, and a small right frontal subdural effusion.
He was initially stable and arterial carbon dioxide was easily kept between 4.0 and 4.5 kPa. However, he suddenly became difficult to ventilate and his oxygen requirements increased. His endotracheal tube remained well secured and still at 18 cm from the lips. Auscultation showed symmetrical poor air entry with hand ventilation. Initially this deterioration was thought to be related to secretions but we were unable to pass the suction catheter down the endotracheal tube. An anterior-posterior chest radiograph was performed showing a tooth shaped radio-opaque foreign body at the tip of the endotracheal tube (fig 1).
A lateral neck radiograph was urgently requested (fig 2). This confirmed that the tooth was actually posterior to the trachea within the upper oesophagus. Its presence within the oesophagus caused posterior wall compression of the trachea resulting in partial obstruction of the endotracheal tube. The tooth (a deciduous first molar that had been wobbly before the fall) was removed successfully by the ENT surgeons under direct vision using a laryngoscope and McGill forceps. This instantly relieved the obstruction. The patient went on to make a complete recovery and was discharged from hospital two weeks later. Oesophageal foreign body is an important cause of tracheal 1 and endotracheal tube obstruction.2 If suspected this can easily be confirmed with a lateral radiograph.
Dr Carroll acts as guarantor for this article. Dr Lo drafted the original clinical details of the patient. Dr Carroll performed the literature review and prepared the final version for publication.
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