Vape grenade: a patient with maxillofacial injuries with C1-C2 fracture secondary to electronic cigarette blast injury
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What would you do in this situation?
The rise of electronic cigarettes has led to an increase in reported injuries, in addition to the various health risks they pose. An adult from the Philippines was admitted to the emergency room after an electronic cigarette exploded during use (figure 1). The explosion caused the patient to fall and briefly lose consciousness. The patient sustained multiple oropharyngeal injuries, oral and neck pain, and transient bilateral upper extremity weakness. Physical examination revealed lacerations on the lips, tongue, and uvula, along with multiple dental fractures (figure 2). A cervical collar was applied to immobilize the neck.
The patient sustained avulsion on the lips and multiple broken teeth after the electronic cigarette exploded.
Radiographs of the chest and pelvis were unremarkable. A CT scan of the neck revealed a comminuted fracture of the anterior arch of the C1 vertebra and a non-displaced fracture of the odontoid process of the C2 vertebra (figure 3). There is a piece of shrapnel located anterior to the vertebral fractures. A contrast study of the neck showed no vascular injury. Given that this is a blast injury, a plain chest CT scan and an otoscopic examination were requested, which were unremarkable. Nasopharyngolaryngoscopy revealed significant swelling of the oropharyngeal area, but there was no complete obstruction. There were lacerations on the tongue and uvula.
The sagittal views of the cervical CT scan show a comminuted fracture of the C1 (red circle) (a). Anterior to the fracture, a hyperdense focus is visible (white arrow) (a), representing shrapnel from the electronic cigarette that penetrated the patient’s oropharynx. The linear track of the shrapnel can be seen (yellow circle) (b). The fracture on the C2 vertebrae is likewise seen (blue circle) (b).
How did we manage the patient?
The surgical team admitted the patient to the intensive care unit for observation and maintained a cervical collar. The team closely observed the patient for the development of signs or symptoms of airway compromise and were prepared to perform bedside cricothyroidotomy if necessary. Since the patient showed no signs of airway compromise, the team opted for a more conservative approach to airway protection, particularly given the importance of neck stability in the context of cervical vertebral fractures. A pre-emptive surgical airway in this patient could have jeopardized the stability of the fractures. Intravenous dexamethasone was given to reduce airway edema. Neurosurgery recommended surgical fixation of the vertebral fractures but opted for a more conservative approach due to the unavailability of the titanium odontoid screws. They maintained the cervical collar for 12 weeks and instructed the patient to limit movement. Plastic surgery repaired the lip avulsion primarily and allowed the tongue to heal with secondary intention. A strict oral hygiene regimen was implemented. The team referred the patient to the dental service for the dental fractures. The patient regained strength and was able to feed orally with no difficulty. The patient was eventually discharged from the surgical intensive care unit, and sent home with instructions to continue wearing the cervical collar for 3 months. Regular follow-up and constant communication were ensured to verify proper application of the cervical collar, and adherence to oral hygiene. The patient remained asymptomatic throughout the follow-up period. The neurosurgeons advised limiting mobility to bathroom visits. At 3 months follow-up, a repeat CT showed stable fractures of the involved vertebrae, hence the cervical collar was removed. The patient had regained full mobility and work.
The case underscores the importance of a multidisciplinary approach to patient management, ensuring that the teams involved are aligned in their strategies. This is especially important in situations where there is resource scarcity. A conservative approach in terms of vertebral fracture stabilization and airway protection is a viable option for patients who do not present with airway compromise or persistent neurologic deficits. Additionally, the case highlights the potential severity of electronic cigarette-related injuries, underscoring the need for increased awareness, further research, and stricter regulation of these devices to prevent future incidents. Reports such as these are important drivers in the promulgation of laws or regulations governing the manufacture and sale of these devices.
Contributors: AALA is the resident team leader responsible for the patient upon admission and the main author of this article. APMM and JJ provided valuable insights to the team for proper management of the patient, as demonstrated in this article. IBT, ESC, and CAS, the team fellows, assured that the team’s decisions regarding patient management were implemented effectively.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; internally peer reviewed.
Ethics statements
Patient consent for publication:
Not applicable.
Ethics approval:
This study involves human participants and was approved by the Jose R. Reyes Memorial Medical Center Ethics Institutional Review Board on December 21, 2023 (approval number 2023-233). The patient signed a consent form allowing the authors to use his case as the basis for this article.
