I
CASE REPORT * ETUDE DE CAS
placement of a nasogastric Inadvertent 'intracranial placement of a nasogstri.c
Inadvertent
intracranial
tube in a patient with severe head trauma Julian S. Adler, MD; Douglas A. Graeb, MD; Robert A. Nugent, MD nadvertent placement of a nasogastric tube within the intracranial compartment is a serious potential hazard, particularly in the management of craniofacial trauma.'-3 We describe a recent case that highlights the risk in the setting of a gunshot wound (even when the missile did not pass through
the floor of the anterior cranial fossa) and illustrates the potential for further intracranial injury.
.f
cy
I
Case report A 26-year-old man was brought to the emergendepartment of a peripheral hospital with a selfinflicted .32-calibre bullet wound to the head. The patient was comatose; he had massive facial swelling and bilateral "racoon eyes." A right
Fig. 1: Anteroposterior (left) and lateral (right) radiographs of skull, showing intracranial location of nasogastric tube; an endotracheal tube is in situ. Note large temporal parietal fracture, entry and exit site fractures, and numerous facial fractures. From the Department ofRadiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC
Reprint requests to: Dr. Douglas A. Graeb, Department ofRadiology, Vancouver General Hospital, 855 W 12th Ave., Vancouver, BC VSZ IM9 668
CAN MED ASSOC J 1992; 147 (5)
LE ler SEPTEMBRE 1992
temporal contact gunshot wound and a left temporal exit wound were present; bleeding was noted from the nose and both ears. The pupils measured 5 mm in diameter and were nonreactive. In response to painful stimulus the left arm and leg extended and the right arm flexed. Endotracheal intubation and insertion of a nasogastric tube were performed, and the patient was transferred to a tertiary care hospital. Initial investigations included skull radiography (Fig. 1) and computed tomography (CT) of the head (Fig. 2). These showed the entry and exit defects through the squamous temporal bones, fractures of the floors of the anterior and middle cranial fossae and extensive comminution of most of the facial bones, with overlying soft-tissue swelling. Also noted were severe generalized brain swelling, pneumocephalus and intracerebral and subarachnoid blood. In addition, the nasogastric tube was seen to have penetrated through the cribriform plate into the intracranial compartment, becoming looped in the interhemispheric fissure before reflecting back on itself anteriorly to penetrate the dorsal midbrain. A diagnosis of brain death was made some hours after admission. (The nasogastric tube had been removed before the patient's death.)
Comments Our case highlights the potential risk of the
malposition of a nasogastric tube in patients with high-calibre gunshot wounds to the head, even when the missile did not pass through the anterior cranial fossa. These injuries will almost always include damage from the effects of the shock wave created by the bullet at some distance from the track of the missile. The floor of the anterior cranial fossa is thus at high risk for fracture. As a result, in 'this type of head trauma blind passage of a nasogastric tube is contraindicated, and gastric intubation should be performed under fluoroscopic guidance or direct vision. An orogastric tube is a third option. In our severely traumatized patient it is unlikely that the placement of the nasogastric tube adversely affected the outcome. However, in a less injured patient such a complication might well have resulted in serious iatrogenic damage, particularly because the tube was advanced far enough to allow it to loop in the intracranial compartment and subsequently to penetrate brain tissue.
References 1. Koch KJ, Becker GJ, Edwards MK: Intracranial placement of a nasogastric tube. Am J Neuroradiol 1989; 10: 443-444 2. Gregory JA, Turner PT, Reynolds AF: A complication of nasogastric intubation: intracranial penetration. J Trauma 1978; 18: 823-824 3. Seebacher J, Nozik D, Mathieu A: Inadvertent intracranial introduction of a nasogastric tube, a complication of severe maxillofacial trauma. Anaesthesia 1975; 42: 100-102
!! |~~~~~~~~~~~~~~~~~~~~ -
S~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Fig. 2: Computed tomograms scans at orbital-roof level (left) and a level 2 cm higher (right), confirming looped intracranial position of nasogastric tube and showing brain swelling, intracranial air, exit site in left temporal region and comminuted fractures of anterior and middle cranial fossae.
SEPTEMBER 1, 1992
CAN MED ASSOC J 1992; 147 (5)
669
CASE REPORT * ETUDE DE CAS
placement of a nasogastric Inadvertent 'intracranial placement of a nasogstri.c
Inadvertent
intracranial
tube in a patient with severe head trauma Julian S. Adler, MD; Douglas A. Graeb, MD; Robert A. Nugent, MD nadvertent placement of a nasogastric tube within the intracranial compartment is a serious potential hazard, particularly in the management of craniofacial trauma.'-3 We describe a recent case that highlights the risk in the setting of a gunshot wound (even when the missile did not pass through
the floor of the anterior cranial fossa) and illustrates the potential for further intracranial injury.
.f
cy
I
Case report A 26-year-old man was brought to the emergendepartment of a peripheral hospital with a selfinflicted .32-calibre bullet wound to the head. The patient was comatose; he had massive facial swelling and bilateral "racoon eyes." A right
Fig. 1: Anteroposterior (left) and lateral (right) radiographs of skull, showing intracranial location of nasogastric tube; an endotracheal tube is in situ. Note large temporal parietal fracture, entry and exit site fractures, and numerous facial fractures. From the Department ofRadiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC
Reprint requests to: Dr. Douglas A. Graeb, Department ofRadiology, Vancouver General Hospital, 855 W 12th Ave., Vancouver, BC VSZ IM9 668
CAN MED ASSOC J 1992; 147 (5)
LE ler SEPTEMBRE 1992
temporal contact gunshot wound and a left temporal exit wound were present; bleeding was noted from the nose and both ears. The pupils measured 5 mm in diameter and were nonreactive. In response to painful stimulus the left arm and leg extended and the right arm flexed. Endotracheal intubation and insertion of a nasogastric tube were performed, and the patient was transferred to a tertiary care hospital. Initial investigations included skull radiography (Fig. 1) and computed tomography (CT) of the head (Fig. 2). These showed the entry and exit defects through the squamous temporal bones, fractures of the floors of the anterior and middle cranial fossae and extensive comminution of most of the facial bones, with overlying soft-tissue swelling. Also noted were severe generalized brain swelling, pneumocephalus and intracerebral and subarachnoid blood. In addition, the nasogastric tube was seen to have penetrated through the cribriform plate into the intracranial compartment, becoming looped in the interhemispheric fissure before reflecting back on itself anteriorly to penetrate the dorsal midbrain. A diagnosis of brain death was made some hours after admission. (The nasogastric tube had been removed before the patient's death.)
Comments Our case highlights the potential risk of the
malposition of a nasogastric tube in patients with high-calibre gunshot wounds to the head, even when the missile did not pass through the anterior cranial fossa. These injuries will almost always include damage from the effects of the shock wave created by the bullet at some distance from the track of the missile. The floor of the anterior cranial fossa is thus at high risk for fracture. As a result, in 'this type of head trauma blind passage of a nasogastric tube is contraindicated, and gastric intubation should be performed under fluoroscopic guidance or direct vision. An orogastric tube is a third option. In our severely traumatized patient it is unlikely that the placement of the nasogastric tube adversely affected the outcome. However, in a less injured patient such a complication might well have resulted in serious iatrogenic damage, particularly because the tube was advanced far enough to allow it to loop in the intracranial compartment and subsequently to penetrate brain tissue.
References 1. Koch KJ, Becker GJ, Edwards MK: Intracranial placement of a nasogastric tube. Am J Neuroradiol 1989; 10: 443-444 2. Gregory JA, Turner PT, Reynolds AF: A complication of nasogastric intubation: intracranial penetration. J Trauma 1978; 18: 823-824 3. Seebacher J, Nozik D, Mathieu A: Inadvertent intracranial introduction of a nasogastric tube, a complication of severe maxillofacial trauma. Anaesthesia 1975; 42: 100-102
!! |~~~~~~~~~~~~~~~~~~~~ -
S~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Fig. 2: Computed tomograms scans at orbital-roof level (left) and a level 2 cm higher (right), confirming looped intracranial position of nasogastric tube and showing brain swelling, intracranial air, exit site in left temporal region and comminuted fractures of anterior and middle cranial fossae.
SEPTEMBER 1, 1992
CAN MED ASSOC J 1992; 147 (5)
669
