The NG tube
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When I was a resident, I remember reading a case report of a trauma patient who had a basilar skull fracture. For reasons I don't remember, the decision was made to insert a nasogastric (NG) tube - it goes into the nose, down the rear of your throat, into the esophagus and then into the stomach.
The purpose of this tube is to drain stomach content. I have inserted hundreds and hundreds of these.
Well, this case was different. The NG tube found its way through the skull fracture, and rather than going down the esophagus, it worked its way into the brain.
This popped up on my twitter feed:
Of note, it says a "non trauma patient."
Nasogastric tube placement is not without risk. A patient admitted for severe hyperemesis in the setting of chronic alcoholism required nasogastric tube placement. Immediately after nasogastric tube placement, his mental status changed dramatically, and he was urgently intubated by an anesthesiologist. Computed tomography imaging (fig. 1) demonstrated the intracranial placement of a nasogastric tube. Neurosurgery was consulted, and it was removed under direct visualization. Although unintended intracranial placement of an nasogastric tube is rare, it has been reported several times, dating back to the 1970s.1 Almost all of these cases, however, were due to facial or head trauma.1,2 Evidence suggests that drug use, specifically cocaine, and chronic alcohol abuse can lead to midfacial anatomical deformities over time, including thinning of the cribriform plate, rendering these patients at risk.3 Anesthesiologists regularly place nasogastric tubes in the perioperative setting.
The rest of the abstract is paywalled (I'm not an ASA member any more, so...)
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Standard trauma practice in head injury is to put the NG tube orally to avoid this. There is a thin bony plate with many holes in it called the cribriform plate separating the nose from the brain. This is allows olfactory nerves to pass from the brain into the nose and gives the sense of smell. (Btw this is also the route that allows those nasty amoebas found in warm lakes in the south to enter the brain through the nose and cause horrible brain abscesses and death. U read about those cases occasionally. )
Weird here in a non trauma case but obviously the chronic severe vomiting made the plate more porous or fractured. So it’s a kind of trauma case. -
Standard trauma practice in head injury is to put the NG tube orally to avoid this. There is a thin bony plate with many holes in it called the cribriform plate separating the nose from the brain. This is allows olfactory nerves to pass from the brain into the nose and gives the sense of smell. (Btw this is also the route that allows those nasty amoebas found in warm lakes in the south to enter the brain through the nose and cause horrible brain abscesses and death. U read about those cases occasionally. )
Weird here in a non trauma case but obviously the chronic severe vomiting made the plate more porous or fractured. So it’s a kind of trauma case.@bachophile yes.
In head injury cases I would never consider a NG tube, but an OG tube.
Cribiform plate trauma can be subtle, or not recognized. In 1973 (!) I was working at a factory (summer job). We had a delivery of raw materials to our factory and I was to direct the unloading of the truck that had backed up to our delivery door.
I hopped up onto the back of the truck. I stood up quickly stood up. I hit the top of my head on the header of the garage door. Within seconds of hitting the top of my head, I felt a rush of fluid into my nose. It tasted sweet. It lasted about a minute. In retrospect, I can't imagine what it could have been other than CSF through the cribriform plate.
Did I have a basilar skull fracture?
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I’ve put in a lot of tubes in awake patients, usually for bowel obstruction. I always tilt the head forward ( chin to chest) and get the patient to swallow the tube, and time it right with the swallow. Not that hard.
But if you want to be a best friend for life (as in removing a thorn from a lions paw) be the one who takes it out when u don’t need it anymore. That’s what I tell residents. You want this patient to love u? Take out his NG tube.
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Funny, Bach.
A few days after my transplant, right after I went to a ‘step down’ unit from ICU, I remember talking to the surgeon who did my transplant.
I said to him, “you might have replaced my lungs, and I’m certainly grateful for that, but my real hero is the respiratory therapist who extubated me. She I would die for.”
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Funny, Bach.
A few days after my transplant, right after I went to a ‘step down’ unit from ICU, I remember talking to the surgeon who did my transplant.
I said to him, “you might have replaced my lungs, and I’m certainly grateful for that, but my real hero is the respiratory therapist who extubated me. She I would die for.”
