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Tue, 21 May 2002 17:09:59 -0500

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Timothy:

These tubes can indeed be dangerous.  See references between the lines.

Barry Armstrong
General Surgeon
Dryden, Ontario, Canada
-----Original Message-----
From:  Timothy Coats

>> perhaps, in need of ventilation and oxygenation.  Can nasal intubation be
> an
>> acceptable option here?
>
> my opinion is no... i wouldn't put anything up the nose of a casualty with
> head injury... the picture of the ng tube coiled inside the cranium
springs
> to mind...
This is a popular myth not backed by evidence. An NG tube (and a nasal
epistat) are narrow hard tubes that can (very rarely) penetrate the cranium.
A nasopharygeal tube is wide and soft and will not go through a base of
skull fracture. (it is also well tolerated by the patient and unlikely to
make them gag.

In our pre-hsopital system we routinely place two nasopharyngeal airways in
head injured patients to help maximise oxygenation. It is important that we
debunk this myth as nasopharyngeal airways have several advantages over
oro-pharyngeal airways but are little used due to the erroneous fear of
cranial penetration.
Muzzi DA. Losasso TJ. Cucchiara RF. Complication from a nasopharyngeal
airway in a patient with a basilar skull fracture. Anesthesiology.
74(2):366-8, 1991 Feb.

There is little need in our pre-hospital system for naso-tracheal intubation
so I cannot really speak from experience. However, in the same way a
naso-tracheal tube is too wide to penetrate the cribriform plate so there
should be little reason to worry. I have seen no reports of cerebral
intubation (!) ...

Marlow TJ. Goltra DD Jr. Schabel SI.(Department of Radiology, Medical
University of South Carolina, Charleston 29425, USA.)

Intracranial placement of a nasotracheal tube after facial fracture: a rare
complication. [see Comment in: J Emerg Med. 1997 Mar-Apr;15(2):243-4 .].
[Review]

Journal of Emergency Medicine. 15(2):187-91, 1997 Mar-Apr.

Abstract
Extensive facial trauma is often associated with fractures to the skull
base, cribriform plate, and sphenoid sinus. Attempted intubation of patients
with facial trauma may result in intracranial penetration and placement of
nasogastric or nasotracheal tubes into the brain. Such a complication
carries significant morbidity and mortality. Intracranial placement of
nasogastric tubes has been reported multiple times in the literature.
Intracranial placement of a nasotracheal tube, however, has been reported
only twice. Such a case is presented, along with a review of the literature
and a discussion. [References: 12]

and head injured patients routinely have nasal intubation in
the intensive care unit.
Tim.
--
Mr. T J Coats
Senior Lecturer in Accident, Emergency and Pre-Hospital Care
Bart's and the Royal London School of Medicine

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Timothy: These tubes can =
indeed be=20
dangerous.&nbsp; See references between the lines.
<DIV align=3Dleft> Barry =
Armstrong</DIV>
<DIV align=3Dleft>General =
Surgeon</DIV>
<DIV align=3Dleft>Dryden, Ontario,=20
Canada</DIV>
-----Original Message----- From:&nbsp; Timothy =
Coats &gt;&gt;=20
perhaps, in need of ventilation and oxygenation.&nbsp; Can nasal =
intubation=20
be &gt; an &gt;&gt; acceptable option here? &gt; &gt; my =
opinion is=20
no... i wouldn't put anything up the nose of a casualty with &gt; =
head=20
injury... the picture of the ng tube coiled inside the cranium =
springs &gt;=20
to mind... This is a popular myth not backed by evidence. An NG tube =
(and a=20
nasal epistat) are narrow hard tubes that can (very rarely) penetrate =
the=20
cranium. A nasopharygeal tube is wide and soft and will not go =
through a base=20
of skull fracture. (it is also well tolerated by the patient and =
unlikely=20
to make them gag. In our pre-hsopital system we routinely =
place two=20
nasopharyngeal airways in head injured patients to help maximise =
oxygenation.=20
It is important that we debunk this myth as nasopharyngeal airways =
have=20
several advantages over oro-pharyngeal airways but are little used =
due to the=20
erroneous fear of cranial penetration. <FONT =

color=3D#ff0000 size=3D3>Muzzi DA. Losasso TJ. Cucchiara RF. =
Complication=20
from a nasopharyngeal airway in a patient with a basilar skull=20
fracture. Anesthesiology. 74(2):366-8, 1991 =
Feb. There is=20
little need in our pre-hospital system for naso-tracheal =
intubation so I=20
cannot really speak from experience. However, in the same way =
a naso-tracheal=20
tube is too wide to penetrate the cribriform plate so there should be =
little=20
reason to worry. I have seen no reports of cerebral intubation (!)=20
...
<DT>&nbsp;</DT>
<DIV>Marlow TJ.=20
Goltra DD Jr. Schabel SI.(Department of =
Radiology, Medical=20
University of South Carolina, Charleston 29425, USA.) </DIV>
<DT>Intracranial placement of a =
nasotracheal=20
tube after facial fracture: a rare complication. [see Comment =
in: J=20
Emerg Med. 1997 Mar-Apr;15(2):243-4 .]. [Review] 
<DT>&nbsp;
<DT>Journal of Emergency Medicine. =
15(2):187-91, 1997=20
Mar-Apr. 
<DT>Abstract 
<DD>Extensive facial trauma is often =
associated with=20
fractures to the skull base, cribriform plate, and sphenoid sinus. =
Attempted=20
intubation of patients with facial trauma may result in intracranial =
penetration=20
and placement of nasogastric or nasotracheal tubes into the brain. Such =
a=20
complication carries significant morbidity and mortality. Intracranial =
placement=20
of nasogastric tubes has been reported multiple times in the literature. =

Intracranial placement of a nasotracheal tube, however, has been =
reported only=20
twice. Such a case is presented, along with a review of the literature =
and a=20
discussion. [References: 12] </DD>
and head injured patients routinely have nasal =
intubation=20
in the intensive care unit. Tim. -- Mr. T J Coats Senior =
Lecturer=20
in Accident, Emergency and Pre-Hospital Care Bart's and the Royal =
London=20
School of Medicine </BODY></HTML>

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Initial trauma management in RTC entrapment - with basilar skull fracture