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Wed, 22 May 2002 15:19:11 +0100

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I am always concerned to read single case reports. There are three possible
culprits; the patient, the device or the carer. As nobody has put together a
series I am inclined to believe the old adage that there is no cavity in the
human body that the ignorant cannot penetrate if they try hard enough. The
plural of anecdote is not science.
  -----Original Message-----
  From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]On
Behalf Of Barry Armstrong
  Sent: 21 May 2002 23:10
  To: trauma-list@trauma.org
  Subject: RE: Initial trauma management in RTC entrapment - with basilar
skull fracture

  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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<DIV>I am=20
always concerned to read single case reports. There are three possible =
culprits;=20
the patient, the device or the carer. As nobody has put together a =
series I am=20
inclined to believe the old adage that there is no cavity in the human =
body that=20
the ignorant cannot penetrate if they try hard enough. The plural of =
anecdote is=20
not science.</DIV>
<BLOCKQUOTE>
 <DIV class=3DOutlookMessageHeader dir=3Dltr align=3Dleft>-----Original Message----- From: =
trauma-list-admin@trauma.org=20
 [mailto:trauma-list-admin@trauma.org]On Behalf Of Barry=20
 Armstrong Sent: 21 May 2002 23:10 To:=20
 trauma-list@trauma.org Subject: RE: Initial trauma =
management in RTC=20
 entrapment - with basilar skull fracture </DIV>
 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=20
 is 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=20
 base of skull fracture. (it is also well tolerated by the patient =
and=20
 unlikely to make them gag. In our pre-hsopital system we =
routinely=20
 place two nasopharyngeal airways in head injured patients to help =
maximise=20
 oxygenation. It is important that we debunk this myth as =
nasopharyngeal=20
 airways have several advantages over oro-pharyngeal airways but are =
little=20
 used due to the erroneous fear of cranial penetration.<FONT=20
 size=3D2> Muzzi DA. Losasso TJ. =
Cucchiara RF.=20
 Complication from a nasopharyngeal airway in a patient with a =
basilar=20
 skull fracture. Anesthesiology. 74(2):366-8, 1991=20
 Feb. There is little need in our pre-hospital system for =

naso-tracheal intubation so I cannot really speak from experience. =
However,=20
 in the same way a naso-tracheal tube is too wide to penetrate the=20
 cribriform plate so there should be little reason to worry. I have =
seen no=20
 reports of cerebral intubation (!) ...
 <DT>&nbsp;=20
 <DIV>Marlow TJ.=20
 Goltra DD Jr. Schabel =
SI<FONT=20
 color=3D#ff0000 size=3D3>.(Department of=20
 Radiology, Medical University of South Carolina, Charleston 29425,=20
 USA.) </DIV>
 <DT>Intracranial placement of a =

nasotracheal tube after facial fracture: a rare complication. =
[see=20
 Comment in: J Emerg Med. 1997 Mar-Apr;15(2):243-4 .]. [Review] 
 <DT>=20
 <DT>Journal of Emergency Medicine. =
15(2):187-91,=20
 1997 Mar-Apr. 
 <DT>Abstract 
 <DD>Extensive facial trauma is often =
associated=20
 with fractures to the skull base, cribriform plate, and sphenoid =
sinus.=20
 Attempted intubation of patients with facial trauma may result in =
intracranial=20
 penetration and placement of nasogastric or nasotracheal tubes into =
the brain.=20
 Such a complication carries significant morbidity and mortality. =
Intracranial=20
 placement of nasogastric tubes has been reported multiple times in the =

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

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Initial trauma management in RTC entrapment - with basilar skull fracture