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Tue, 28 May 2002 20:42:03 -0500

John:

I wholly agree with your first and third paragraphs.

I gave the references and abstracts to show that
inserting tubes in the noses of patients with cranio-facial
injuries is not wholly benign.  Some in this mailing list
had claimed otherwise.  :-(

Several times by literature reports, such tubes have passed
into the brain. If just 0.05% of such tubes enter the brain,
it is too frequent, considering the devastating results.

For the head-injured patient needing pharyngeal, endo-tracheal
or gastric intubation, the safer oral route should be chosen
when possible.

As you say, the risks of nasal intubation must be seen in
perspective.  They should not be ignored or made light of,
in training or in practice.

Barry Armstrong
General Surgeon
Dryden, Ontario, Canada

-----Original Message-----
From: John Black

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

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Nasal airway use in base of skull fractures - ATLS guidelines