C O RR E S P O N D E N C E 1 1 07
atropine 120 mcg was given intravenously. Ketamine was
administered intravenously in boluses of 10 mg up to
40 mg in total. The right nostril was sprayed with 0.6 ml
of 1 in 10 000 adrenaline and a Rusch Nasopharyngeal
Airway inserted. To the airway was attached a size 5
portex connecter to which an Ayre’s T-piece was con-
nected, allowing improved oxygenation. The patient
relaxed sufficiently for a size 2 standard Laryngeal Mask
Airway to be inserted. The surgeon was then able to
remove the toothbrush without incident or bleeding,
allowing intubation of the trachea. On transfer to theatre
the wound in the patient’s cheek was explored and
sutured. There were no postoperative complications.
Penetrating oral trauma in children is not uncommon
and many minor cases may not even present for treatment
(2). Reported complications include retropharyngeal
abscess, mediastinitis, emphysema (4), internal carotid
artery aneurysm (3) and airway obstruction (2).
An impacted foreign body occluding access to the
airway is rare. Similar reports exist in the dental literature,
but to our knowledge, there has been no examination of
this issue in an anaesthetic journal.
Younessi describes a 4-year-old girl with a similarly
impacted toothbrush. Induction was intravenous after
preoxygenation with nasal prongs. After the child was
anaesthetised the handle of the toothbrush was removed
with the aid or orthopaedic bolt cutters. The child was
then ventilated and intubated without difficulty (5). This
ingenious solution would require reasonable access to
the oropharynx, which was not available in either of the
two cases that we have presented. In addition, failure in
this technique could risk loss of the airway in an apnoeic
child.
The management of both of our cases relied on a
cautious approach with spontaneous ventilation main-
tained as a priority. As both of the toothbrush heads were
lodged lateral to the mandible of the ramus the possibility
of serious complications was low (5). However, the
difficulty remained of maintaining the airway when access
to it was compromised. The use of ketamine and the
Laryngeal Mask Airway was central to the management of
both cases.
James Ellwood
Oliver Dearlove
Vesna Colovic
Rita Vashisht
Department of Anaesthesia, Royal Manchester Children’s
Hospital, Pendlebury, Manchester, UK
(email: jamesellwood@doctors.net.uk)
Acknowledgement
We are grateful that colour reproduction of artwork was
made possible by a grant from the Stanley Fould Fund.
 2008 The Authors
Journal compilation  2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 1102–1143
Supporting Information
Additional Supporting Information may be available in the
online version of this article:
Figure S1. Case 2: toothbrush firmly impacted.
Figure S2. Case 2: the toothbrush handle prevented
adequate preoxygenation.
Figure S3. Case 2: the Rusch nasal airway was left in situ
after placement of the Laryngeal Mask Airway and
removal of the toothbrush.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
References
1 Walker RWM, Allen DL, Rothera MR. A fibre-optic intuba-
tion technique for children with mucopolysaccharidoses
using the laryngeal mask airway. Paediatr Anaesth 1997; 7:
421–426.
2 Law RC, Fouque CA, Waddell A et al. Lesson of the week:
penetrating intra-oral trauma in children. Br Med J 1997; 314:
50–51.
3 Sasaki T, Toriumi S, Asakage T et al. The toothbrush: a rare but
potentially life threatening cause of pharyngeal trauma in
children. Pediatrics 2006; 118: 1284–1286.
4 Chambers N, Hampson-Evans D, Patwardhan K et al.
Traumatic aneurysm of the internal carotid artery in an
infant: a surprise diagnosis. Pediatric Anesthesia 2002; 12: 356–
361.
5 Younessi O, Alcaino E. Impalement injuries of the oral cavity in
children: a case report and survey of the literature. Int J Paediatr
Dent 2007; 17: 66–71.
Improving electrical safety for patients
with Epidermolysis bullosa
doi:10.1111/j.1460-9592.2008.02715.x
SIR—This case report describes a method to provide safe,
effective, and low risk electrical grounding for patients
with Epidermolysis bullosa (EB) who require surgery and
anesthesia. While improper grounding in the surgical
patient can lead to equipment failure and tissue damage,
most grounding devices are adhesive and present the risk
of further skin damage to EB patients. The methods
described have been approved by our biomedical engi-
neers and used successfully for over 1 year without
adverse effects. We feel this is an improvement in patient
care for EB patients.
1 10 8 CORRESPONDENCE
Epidermolysis bullosa, a rare but ultimately fatal
genetic disorder, presents unique challenges to the pedi-
atric anesthetist. These children come to us requiring
multiple, repeated surgical procedures including esopha-
geal dilation, plastic repair of deformed or unusable
extremities, dental restoration and dressing changes (1).
EB results from the abnormal separation of the layers of
the skin and ⁄ or mucosa with resultant blistering, scarring,
deformity, and dysfunction.
The incidence of EB is about 2–4 per 100 000 (2). EB has
three different clinical forms (EB simplex, junctional EB
and dystrophic EB) based on the morphological appear-
ance and histological site of the separation of the skin
layers. EB simplex is a milder form and fortunately the
most common (90%) where the disease is confined to
above the basement membrane of the skin. Junctional and
dystrophic EB are more severe and can involve the epi-
glottis, the nasal and oro-phyranx, esophagus, intestines,
and the urogenital system. Even the slightest friction can
cause the skin layers to separate. This skin separation and
the subsequent blistering, ulceration, and scar formation
are not only disfiguring but also result in dehydration,
poor nutrition, impaired temperature homeostasis, and
end stage high output cardiac failure.
It is imperative for the anesthetist involved in the care of
children with EB to use extreme caution in avoiding
friction injury to the skin. All adhesive surface need to be
removed from pulse oximeter probes, EKG pads and
electrosurgical grounding pads. However, decreasing the
adherent proprieties of these electrical devises can pose
additional dangers (3). The risk of high frequency induced
electrical burns or micro-current cardiac arrhythmias and
damage results from improper grounding or excessive
leakage current.
Damage occurs when electrical energy passes through
tissue rather than through an electrically safe grounding
device to reach a common grounding source. Isolated
electrical power systems used in the operating rooms do
not completely eliminate these risks. In particular, EKG
monitoring and electrosurgical units for patients with EB
have been limited by the inability to use appropriate
grounding for fear of skin damage from the adhesive
surfaces on conductive padding, either EKG or electro-
cautery grounding pads.
Decreasing the amount of electrical energy or the
distance through which it transverses tissue can decrease
this risk. Most reductions in current density in these
patients with EB have been achieved through the use of
lower voltage hand-held electrosurgical instruments or
modified EKG pads with less adhesive strength. However,
this reduction in energy flow as a result of poorly applied
pads or the exclusive use of low-voltage cautery also
reduces electrical efficacy. At Stanford, we have devised a
method of safe electrical conduction without compromise
of electrical flow or skin safety in EB patients.
Journal compilation  2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 1102–1143
Figure 1
Placement of ECG electrodes on water-based gels pads (3M
‘Defib pads’ 2346N).
We are currently using water-based gels pads (3M
‘Defib pads’ 2346N) to improve conductivity for both EKG
electrodes and electrocautery grounding. These water-
based pads do not cause skin damage in EB patients
because they are non-adhesive. The pads are applied
directly to the patient’s skin and then the EKG or
grounding pads applied over the water based gel pad
(Figure 1). The water-based defibrillator pads reduce
trans-cutaneous impedance and improve electrical con-
ductivity without applying adhesive materials to the skin
of EB patients. Care must be taken that the defibrillator
pad makes contact completely with the skin surface and
the pads are in full contact with the gel to avoid air
bubbles, which reduce the available current density area
separating the skin, the gel, and the pads. These pads are
up to 90% water and prolonged exposure to air can reduce
the conductive potential. Pads should be changed or
covered to avoid evaporation if the procedure lasts more
than 30 min (4).
We have found the resultant ECK tracing to be of
reliably superior quality to past tracings where EKG pads
were affixed to the patient after the adhesive removed. In
the case of electrocautery grounding pads, our modified
technique for application has been approved by our
biomedical engineers and the safety monitoring of ade-
quate grounding by the return electrode monitor (REM)
has been satisfied on all electro-cautery models currently
in use. Additionally we have not seen any electrical burns
with the use of electrocautery.
Alice A. Edler
Radhamangalam J. Ramamurthi
Glenn A. Valenzuela
Department of Anesthesia, Section of Pediatric Anesthesia,
Stanford University School of Medicine, Stanford, CA, USA
(email: edlera@stanford.edu)
 2008 The Authors
 C O RR E S P O N D E N C E 1 1 09

References necessary to perform general anesthesia using facial mask

1 Herod J, Denyer J, Goldman A et al. Epidermolysis bullosa in
children: pathophysiology, anaesthesia and pain management.
Paediatr Anaesth 2002; 12: 388–397.
2 Wolff K, Goldsmith LA, Katz SI et al. Fitzpatrick’s Dermatology in
General Medicine, 7th edn. New York, NY: The McGraw-Hill
Companies, Inc, 2008.
3 Hutchisson B, Baird MG, Wagner S. Electrosurgical safety.
AORN J 1998; 68: 830–837; quiz 8.
4 Drury NE, Petley GW, Clewlow F et al. Evidence-based guide-
lines for the use of defibrillation pads. Resuscitation 2001; 51:
283–286.
Epydermolysis bullosa: a new technique
for mask ventilation
doi:10.1111/j.1460-9592.2008.02594.x
(halogenated anesthesia: sevoflurane) because of high risk
of intubation with orotracheal cuffed ⁄ uncuffed tubes
usually utilized in healthy pediatric patients (3).
The skin of these patients is very fragile and poorly
resistant to the tangential pressures; for these motives use
of this technique is very difficult. To avoid the appearance
of cutaneous ulcers and traumatic wounds, is possible to
use absorbent and gently adhesive medications (Figures 1
and 2) constituted from:
1. a soft silicone wound contact layer (Safetac, MEPILEX
with SAFETAC TECHNOLOGY – MÖLNLYCKE
HEALTH CARE AB (Publ) – Box 13080, SE-402 52
Göteborg, Sweden) (Figures 1 and 2)
2. a flexible absorbent pad of polyurethane foam
3. an outer film witch is vapour permeable and waterproof

The Epidermolysis Bullosa (EB) is a rare genetic disease

characterized by the presence of extremely fragile skin and
recurrent blisters formation resulting from mechanical
friction or trauma.
Pathology manifests in different clinical aspects (1):
1. Simplex EB (blisters within the epidermis),
2. Junctional EB (at the level of lamina lucida within the
basement membrane zone) and
3. Dystrofic EB (lesions are located at level of lamina
densa, with an important scarring component).
The most serious forms can be deadly since intrauterine
e ⁄ o neonatal age; the first signs are manifested in neonatal
age or in the first months of life.
EB involves the skin of the whole body and the great
part of the mucous surfaces, included the oral cavity,
esophagus, stomach, intestines, lungs, bladder, genital Figure 1
The soft silicone wound contact layer (Safetac).
region and eyes.
Patients generally die in the second–third ten of life and
the exitus is related to the general compromised state
correlated to the Multiorgan failure (MOF).
From January 2001 to March 2008, in our Department of
Plastic and Reconstructive Surgery together with the
University Department of Anesthesia, 20 patients (range
3–45 years old; 14M–6F; particularly for hands and feets)
were treated with microsurgical technique (2).
All the subjects’ joints to our observation were
performed using the followings anesthesiological tech-
niques:
1. regional anesthesia (particularly brachial plexus)
2. deep sedation with fentanyl and propofol plus local
anesthetic infiltration
3. deep sedation with ketamine and fentanyl plus local
anesthetic infiltration
All the patients were submitted to numerous medica- Figure 2
tions. First 3–5 medications are very painful so it is The side view of the layer (Safetac).

 2008 The Authors

Journal compilation  2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 1102–1143