Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 5, 2010, pp. 802-804

Neurology India, Vol. 58, No. 5, September-October, 2010, pp. 802-804

Letter to Editor

Fatal inadvertent intracranial insertion of a nasogastric tube

Yam B Roka¹, M Shrestha², PR Puri¹, S Aryal²

¹ Division of Neurosurgery, Neuro Hospital, Biratnagar, Nepal
² Division of Anesthesiology, Neuro Hospital, Biratnagar, Nepal

Correspondence Address:
Yam B Roka
Division of Neurosurgery, Neuro Hospital, Biratnagar
Nepal
dryamroka@yahoo.com

Date of Acceptance: 27-Jul-2010

Code Number: ni10227

PMID: 21045525

DOI: 10.4103/0028-3886.72191

Sir

Insertion of a nasogastric (NG) tube is one of the most common procedures undertaken worldwide and is recommended in unconscious patients. The insertion of the NG tube is associated with a number of complications: esophageal perforation, bronchopleural fistula, knotting of the tube, pneumothorax, laryngeal injuries, pulmonary hemorrhage, pneumomediastinum and death. ^[1],[2],[3] Of all these complications, the most lethal and uncommon complication is the intracranial insertion, first described by Martinelle et al. in 1974. ^[4] There are four possible pathways by which the NG tube can enter intracranially: a skull base fracture extending across the cribiform plate, a comminuted fracture involving the floor of the anterior cranial fossa, an unusually thin cribiform plate and a cribiform plate thinned by sinusitis. ^[5]

A 55-year-old man was brought to the emergency room for head injury due to a corn thrasher, an hour after the incident. He had been cutting the corn when he got pulled and sustained injury when his head struck the rotating wheel of the machine. He was immediately pulled away by the surrounding workers and rushed to the hospital. On examination there was an open wound over the forehead with active bleeding, periorbital edema and prolapsed brain matter. The Glasgow Coma Scale (GCS) score was 9 with bilaterally small reactive pupils. Primary wound care and resuscitation were done, following which he was taken for emergency computerized tomography (CT) of the head which showed comminuted fracture of the anterior cranial fossa with loss of part of the midline frontal bone and herniated brain [Figure - 1]. There was associated left orbital hematoma with fracture of the orbital roof. While the patient was planned for immediate exploration of the wound, a nasogastric tube was inserted by one of the medical personnel with suctioning of some blood-like contents.

At operation the wound was explored. On removal of the dead skin and contused brain, the NG tube was seen to be projecting inside the brain on the left side and it was slowly withdrawn to expose the entire 60 cm of the tube [Figure - 2]. The site of intracranial entry was through the fractured anterior cranial fossa floor. The tube was then cut at the level of the fracture, and the two ends were pulled out separately. All of the contused brain was sucked out and hemostasis was secured. Dural defect was closed with synthetic dura and the frontal sinuses were exenterated. Pericranium was used to augment the anterior cranial fossa defect. The epidural dead space was covered with gel foam and the frontal fracture was realigned. A closed suction drain was placed and the wound closed primarily. Postoperatively an NG tube was inserted under direct vision, tracheostomy done and he was kept on ventilator. There was no cerebrospinal fluid (CSF) leak. He had not shown any improvement and repeat CT brain done on day-4 showed bilateral severe edema, effacement of basal cisterns, loss of gray matter-white matter interface and resolving hematoma along the NG tract on the left side. There was good alignment of the frontal bones with no local CSF collection [Figure - 3]. Postoperatively the GCS score did not improve and he succumbed to his illness on the sixth postoperative day.

NG tube insertion is a procedure which due to its commonness may not receive the attention it is supposed to receive. In the emergency setting, most of the insertion is done by the paramedics and the junior doctors, who may not be aware of the dangerous sequel of inadvertent insertion of the tube. The serious and sometimes fatal consequences of intracranial placement are secondary to intracranial hematoma, brain tissue suctioning, meningitis, damage to vital structures and cerebrospinal leak. In most of the cases, it is difficult to assign the cause of morbidity to the intracranial NG tube insertion as there is always associated severe craniofacial injury. In this case, the cause seems to be the primary brain damage although the intracranial NG tube had a significant contribution considering the fact that there was 60 cm of coiled tube in the left hemisphere and also because some suctioning was done during the initial placement of the tube. The management of intracranial insertion of NG tube is removal of the tube under direct observation by craniotomy or by careful retrieval via the nasal route. ^[6],[7],[8] There is no clear consensus in literature as to which approach is better. The reported mortality of intracranial insertion is as high as 64%, and hence prevention of this complication is important in all cases with maxillofacial trauma. ^[9]

Although the insertion of NG tube is a very simple procedure with very low complication rate, the attending physician or paramedic must always ensure that there is no associated maxillofacial injury and that the correct position is always confirmed clinically (by either aspiration of gastric contents or by auscultation of air in the stomach) or radiologically. In all cases of multiple fractures of the anterior cranial fossa base and faciomaxillary injuries, a protocol should be made wherein an orogastric tube rather than a nasogastric tube is inserted unless there is facility for direct insertion by an anesthetist using laryngoscopy or flexible endoscopy to prevent this dreaded complication. This lesson is especially important for the young doctors, paramedics and nurses, who are usually the first to receive and manage the trauma patients.

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