Intracranial Insertion of a Nasopharyngeal Airway in a Patient with Craniofacial Trauma

Military Medicine, Jun 2004 by Martin, Jonathan E, Mehta, Rajesh, Aarabi, Bizhan, Ecklund, James E, Et al

Intracranial insertion of a nasopharyngeal airway is an unusual and catastrophic complication of airway management in the patient with a severe closed head injury. We present an unfortunate 43-year-old patient with intracranial insertion of a nasopharyngeal airway during trauma resuscitation. The nasopharyngeal airway was removed. Attempts to resuscitate the patient were continued, but were eventually unsuccessful. Blind nasopharyngeal airway insertion may result in iatrogenic injury when used in the head-injured patient. Oropharyngeal airways may be used to assist with ventilation. However, it is preferable to definitively secure the airway through inline endotracheal intubation or with surgical techniques in this patient population. Should violation of the skull base occur, removal is accomplished in the controlled environment of the operating room.

Introduction

Establishment and maintenance of a patent airway is a fundamental goal of any trauma resuscitation. In the patient with craniofacial injuries, the urgent need for an airway must be tempered by the hazards inherent in manipulation and instrumentation of a patient with the potential forbasilar skull fracture and/or cervical spine injury. We report an unusual complication of nasopharyngeal airway insertion in a multitrauma patient.

Clinical Presentation

A 43-year-old man was involved in a motorcycle accident in which he was thrown head-first into a guardrail, suffering severe craniofacial trauma. On arrival to the scene, paramedics found the patient unresponsive with his airway obstructed. Because of severe facial trauma and the potential for cervical spine injury, endotracheal intubation was not attempted. Bilateral nasopharyngeal (N-P) airways were placed in an attempt to establish a patent airway. Aggressive resuscitation succeeded in restoring normal vital signs. he was transferred to the closest medical facility where endotracheal (ET) intubation was accomplished. The postintubation head computed tomography (CT) scan (Fig. 1) revealed Traumatic Coma Data Bank diffuse injury grade III1 injury, with comminuted fractures of the anterior skull base and pneumocephalus. Placement of the right-sided N-P tube into the anterior cranial fossa was noted. Both N-P airways were subsequently removed, and the patient was then transferred to our facility for further management.

Upon arrival to our facility, the patient's vital signs were stable. Detailed examination revealed severe neurological compromise. Glasgow Coma Score at the time of admission was 3T (E1V1M1). His pupils were 6 mm and nonreactive bilaterally and corneal reflexes were absent. Cough, gag, and spontaneous respirations were present. Repeat head CT remained diffuse injury III with worsened cerebral edema. The patient's injury was catastrophic. After discussion with the family and in accordance with their wishes, no aggressive treatment was undertaken, and the patient expired.

Intervention

Intracranial placement of a N-P airway is an unusual complication with a single additional case report in the existing literature.2 In 1991, Muzzi et al.2 reported intracranial N-P airway placement by an emergency department physician in a 46-yearold woman with open craniofacial fractures after a motor vehicle accident. The patient died as a result of her injuries. In our case, the N-P airway was placed by an emergency medical technician at the accident scene. This emphasizes the role of the nonphysician provider in prehospital airway management and the attendant risks of airway management in this setting. In this case report, it is likely that intracranial placement of the N-P airway did not alter the outcome of the patient's traumatic brain injury. Nevertheless, it could have significantly impacted the patient's neurological outcome had he been able to be saved.

Severe facial fractures complicate airway management by distorting normal anatomy and obscuring visualization of the airway with blood, secretions, and other debris. Concern for cervical spine injury impedes optimal patient positioning for ET intubation. An oropharyngeal (0-P) airway can be used for temporary maintenance of an airway while awaiting definitive care; it relieves airway obstruction by displacing soft tissues from the posterior pharynx, allowing for mask ventilation of the patient. 0-P airways are often poorly tolerated by combative patients. However, in the comatose patient with craniofacial injury, they are the noninvasive airway of choice.

A surgical airway by cricothyroidotomy or tracheostomy is the preferred method of maintaining airway patency in these patients when inline ET intubation cannot be performed.3 Surgical airway placement bypasses the area of abnormal anatomy and allows for direct passage of an ET or tracheal tube for emergency airway access. It also maximizes the ability to oxygenate and ventilate when compared with noninvasive methods. Variations of this technique are widely taught to providers in Basic Trauma Life Support4 and Advanced Trauma Life Support American College of Surgeons2 courses and are essential skills for all emergency medical providers.