Insertion of a nasopharyngeal airway in a patient with head trauma

[msenecal]

Whats your opionion on inserting a nasopharyngeal airway on a patient with a head injury? I have just returned from a call with a unresponsive patient who had unintentionally dismounted her ATV. On our arrival decorticate posturing, blood from the nose, small amount of facial trauma (no le fort fx)x head wound, clinched jaw, noisy airway, 02 sat 92% on high flow O2. I inserted (no RSI) nasopharyngeal airway sats improved to 100% airway quiet. I have no issues with my care however it started a healthy discussion about using a nasopharyngeal airway on patients with facial trauma due to possible intracranial insertion. PHTLS pretty well states thats untrue. What do you think?

[celticcare]

If the sats improved, overall airway maintance was achieved and you had no other options, then hell better than letting her further injury due to secondary hypoxia.

Its a tough one to weigh up, NPA or nothing really, EMS is full of judgement calls, and you made one. If I started feeling anything that would deviate during the insertion I would stop, we all know the shape of the nose and airway basically is like a sideways J so if i felt it start to veer off the wrong way, I'd withdraw.

No other options, I would have probably gone the same path as you.

Scotty

[Doczilla]

Every patient without an airway dies. All other considerations are secondary to this.

The concern over placing an NPA in a patient with a possible basilar skull fracture are based on the theoretical danger that you could poke the NPA into the cranial vault. Everyone has seen the x-ray of an NG tube curled up in the head after being placed on someone with a BSF. NPAs are much larger diameter than NG tubes, and if the patient has such a large BSF as to admit one of these into the brain, the patient has much bigger problems than you can fix.

At the BLS level, you have no other options at this point but an NPA with a hypoxic head trauma patient with a clenched jaw. At the ALS level, you have to consider the possible risks of RSI in this patient, which are not insignificant.

If they need an airway, give them one.

'zilla

[chbare]

Obviously, this is a judgment call; however, this NPA argument appears to be somewhat of a sacred cow that EMT instructors seem to pass off on students. Obviously, it could be a problem with a severe enough injury; however, has anybody ever really looked at the literature?

How many VERIFIED cases of intracranial NPA placement could you find? I have been able to find two cases. Two cases of something that is considered unusual and rare at best, is some how debated several times a year on various EMS forums.

Take care,

chbare.

[Jeepluv77]

I was taught last semester, in my emt-b training, that npa's were completely contraindicated with facial trauma. I always thought that didn't sound right if it was only basic's on scene and your pt needs an airway. I could see using caution, of course. Seems that a lot of stuff is like that. Like two large bore iv's for just about every pt and a nrb at 15 liters for all pts.

Edited April 9, 2009 by Jeepluv77

[croaker260]

Obviously, this is a judgment call; however, this NPA argument appears to be somewhat of a sacred cow that EMT instructors seem to pass off on students. Obviously, it could be a problem with a severe enough injury; however, has anybody ever really looked at the literature?

How many VERIFIED cases of intracranial NPA placement could you find? I have been able to find two cases. Two cases of something that is considered unusual and rare at best, is some how debated several times a year on various EMS forums.

Take care,

chbare.

I would love to see the references for those two cases, as I was unwaware of ANY that werent NG tubes (wich are completely different, obviously).

I assume that the OP was an EMT, simply because if I was going to insert an NPA... I would go ahead and do a Nasal ETT (I a bit old school) if for some reason RSI/MAI was not an option.

Other than getting an ass chewing by the recieving doc or internist.....any clinical based reasoning behind Nasal ETT over NPA assuming both are an option and RSI/MAI isnt?

[chbare]

http://findarticles.com/p/articles/mi_qa39...06/ai_n9413350/

This describes the two cases I knew of. It also appears, there is a case study of intracranial NPA placement in 2007. Apparently, a person sustained extensive trauma from a GSW to the face in Iraq and the medical provider inadvertently placed a NPA into the cranial cavity.

So, now we have three cases since the 1970's. Funny, we tell people to absolutely not place a NPA for any head trauma based on a few cases, yet refuse to admit we may have real problems with it comes to procedures such as ETI. Even though we have significantly more data on these other topics.

Take care,

chbare.

Edited April 10, 2009 by chbare

[brentoli]

I am not coming at this with any medical evidence... just a question in theory.

How can you evaluate the injuries that were not sustained by refraining from placing an airway?

[zzyzx]

Does anyone know the # of reported cases of intracranial placement of an ET tube after nasotracheal intubation?

I wonder how many cases went unreported....

[FireMedic65]

I would love to see the references for those two cases, as I was unwaware of ANY that werent NG tubes (wich are completely different, obviously).

I assume that the OP was an EMT, simply because if I was going to insert an NPA... I would go ahead and do a Nasal ETT (I a bit old school) if for some reason RSI/MAI was not an option.

Other than getting an ass chewing by the recieving doc or internist.....any clinical based reasoning behind Nasal ETT over NPA assuming both are an option and RSI/MAI isnt?

I have seen an x-ray picture on trauma.org a few years back that showed an NPA up in the cranial vault. I will try to track it down.