DENTAL BRACES AS A CAUSE OF AIRWAY OBSTRUCTION

Letters

CJEM 2009;11(6):514-515

To the editor: A 15-year old boy was involved in a high-speed single-vehicle crash in which he was the passenger and required extrication with the jaws of life. He had obvious severe head injuries, including brain protrusion. Prehospital intubation was unsuccessful because of reported “clenching.”

On arrival at the emergency department, the patient’s oxygen saturation was recorded at 76%, with an obvious facial smash. Attempts to open his mouth failed because of apparent clenching of his teeth. Nasopharyngeal airway was considered to be relatively contraindicated because of the facial injuries. Vigorous 2-handed bag mask ventilation with in line stabilization improved his oxygen saturation to 82%, with significant high pressure air leak around the mask. Closer examination revealed that his upper gums were visible between his lips, but not the occlusive area of the incisors. Our initial impression was that he had had his jaw wired shut. Further examination revealed that the mucosa of his lower lip had become closely and tightly fastened to the braces on his upper teeth, effectively sealing his mouth shut (including the interdental spaces). We were able to free up the lip and open the mouth by pulling the lip cephalad and “popping” the mucosa off each brace fastener by sliding an index finger between the lower teeth and inner lip. An uneventful lightwand intubation followed, with restoration of 100% oxygen saturation.

To our knowledge this occurrence, which might easily have led to the patient’s death in the field, has not been described before.

We presume that, in spite of his facial injuries, his nostrils had enough patency to allow enough oxygenation to sustain him during transport and initial ED assessment. He did, however, experience a prolonged period of hypoxia. Unfortunately, his injuries subsequently proved to be fatal.

Samuel G. Campbell, MB BCh, CCFP(EM), Dip PEC (SA), CHE

Associate Professor of Emergency Medicine, Dalhousie University Chief, Department of Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS

Glen Etsell, CCP

Department of Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS