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Wed, 22 May 2002 19:55:39 +0100

Barry,

These case reports (below) have highlighted an extremely rare occurence that 
has resulted from serious training deficiencies in the insertion of 
nasopharyngeal airways. Intracranial placement should NEVER occur if 
nasopharyngeal airways are inserted correctly.

I suspect that as a consequence of these and other case reports, the ATLS 
subcommittee of the American College of Surgeons has advocated that these 
devices should not be used to relieve airway obstruction  associated with 
skull base fractures. Tragically this advice has been widely taken up by EMS 
systems throughout the world. This results in these types of patients being 
delivered to emergency departments hypoxameic as a consequence of unrelieved 
airway obstruction, with needless secondary neurological injury, on a 
regular basis.

It is essential in my view that the risk associated with the use of nasal 
airways with this injury pattern is kept in perspective and that the nasal 
airway guidelines taught on ATLS courses is updated as rapidly as possible.

John Black
Emergency Department
John Radcliffe Hospita, Oxford UK

Message: 11
From: "Barry Armstrong" <docbear@sympatico.ca>
To: <trauma-list@trauma.org>
Subject: RE: Initial trauma management in RTC entrapment - with basilar 
skull
fracture
Date: Tue, 21 May 2002 17:09:59 -0500
Reply-To: trauma-list@trauma.org

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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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Nasal airway use in base of skull fractures - ATLS guidelines