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• Intracranial placement of a nasopharyngeal airway in a gun shot victim.
  Peter F Mahoney
  Published on: 29 April 2016

• Published on: 29 April 2016

  Intracranial placement of a nasopharyngeal airway in a gun shot victim.

  • Peter F Mahoney, Consultant Anaesthetist
  • Other Contributors:
    • David Steinbruner, Robert Mazur

  Dear Editor

  Further to the review by Roberts et al (1) and the letter by Ellis et al (2) we wish to report another case of intracranial placement of a nasopharyngeal airway.

  The patient was an adult female who had been shot in the head and dumped by the roadside in Baghdad in 2006. She was found by a military patrol who gave first aid. The medic on scene noted she was deeply unconscious, had facial in...

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  Dear Editor

  Further to the review by Roberts et al (1) and the letter by Ellis et al (2) we wish to report another case of intracranial placement of a nasopharyngeal airway.

  The patient was an adult female who had been shot in the head and dumped by the roadside in Baghdad in 2006. She was found by a military patrol who gave first aid. The medic on scene noted she was deeply unconscious, had facial injuries and had an obstructed airway. A nasopharyngeal airway was placed and she was transferred rapidly to the US Combat Support Hospital (CSH) in the International Zone.

  At the CSH she underwent resuscitation (including endotracheal intubation) and CT scan to confirm the extent of her injuries. CT scan demonstrated the path of the bullet through the frontal region of the casualties head, damage to the cribriform plate and intracranial placement of the nasopharyngeal airway. The patient later died from her injuries.

  The Emergency Medicine Attending commented that, on initial examination, the facial trauma was easy to miss and the mid face was structurally stable. The extent of the injury would have been very difficult to assess in the field.

  An internet search for intracranial placement of nasopharyngeal airways produced the reports by Muzzi et al (3) and Schade et al (4) [as referenced by Roberts (1) ] and an additional case report from Martin et al (5).

  This latter report describes a patient with severe craniofacial trauma from a motorcycle accident who had bilateral nasopharyngeal airways sited by the prehospital provider, one of which was placed intracranially. Martin et al state that airway management in these patients is problematic and, where orotracheal intubation is not practical or possible, the standard of care for airway management is a surgical airway. They recommend the oropharyngeal airway as the non invasive airway of choice and that nasopharyngeal airways should be avoided as they have the potential for worsening intracranial injury.

  During our time in Baghdad we regularly cared for patients with blunt and penetrating head injury and the patient we describe is the only case of intracranial nasopharyngeal airway placement we came across.

  We still recommend its use for military prehospital providers. Prehospital care in a high threat or potentially high threat environment has to be about compromises. Current UK Battlefield ATLS teaching (6) builds on the work of Butler et al (7) and teaches that clinical care has to be modified according to the threat environment (BATLS is the UK military derivation of ATLS).

  The nasopharyngeal airway can be rapidly placed in a casualty and usually stays in place when the casualty is moved to a lower threat area. We agree that, when the situation allows, the airway should be placed carefully as described by Roberts (1).

  David Steinbruner Evans Army Community Hospital, Ft. Carson, Colorado, USA.

  Robert Mazur Winn Army Community Hospital, Ft.Stewart, Georgia, USA.

  Peter F Mahoney Royal Center for Defence Medicine, Birmingham, UK.

  Competing interest:Dr Mahoney is one of the authors of the UK BATLS course and instructs on the course.

  REFERENCES: Intracranial placement of a nasopharyngeal airway in a gun shot victim

  1.Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J 2005; 22: 394-396.

  2.Ellis DY, Lambert C, Shirley P. Intracranial placements of nasopharyngeal airways: is it all that rare? Emerg Med J 2006; 23: 661.

  3.Muzzi DA, Loasso TJ, Cucchiara RF. Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anaesthesiology 1991;74: 366-8.

  4.Schade K, Borzotta A, Michaels A. Intracranial malposition of nasopharyngeal airway. J Trauma 2000;49 (5): 967-8.

  5. Martin JE, Mehta R, Aarabi B, Ecklund JE, Martin AH. Intracranial insertion of a nasopharyngeal airway in a patient with craniofacial trauma. Military Medicine 2004;169: 496-7.

  6. BATLS 2005. Joint Service Publication 570. First 7 chapters published as Supplement to Journal of the Royal Army Medical Corps 2006, vol 152 no 2

  7. Butler FK, Hagmann J, Butler EG. Tactical Combat Care in Special Operations. Military Medicine 1996; volume 161, supplement 1

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  Conflict of Interest:
  None declared.

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