Abstract
Misdirection of nasogastric tubes into the cranial cavity of trauma patients is a well‐understood complication that has been well documented in the literature. As a result, recommendations have been established in the use of nasogastric tubes where trauma or suspected skull fractures are identified. Orogastric tube placement is also a commonly performed procedure during trauma resuscitation attempts and is often necessary during patient management. However, no literature currently exists demonstrating misdirection of orogastric tube placement into the spinal canal following trauma and as such, no similar recommendations exist. We review a case of orogastric tube misplacement into the spinal canal due to atlanto‐occipital dissociation and suggest a recommendation for prevention.
1. PATIENT PRESENTATION
A 28‐year‐old, unrestrained front‐seat passenger presented to the emergency department following a motor vehicle collision resulting in complete ejection from the vehicle and cardiac arrest. The patient received bystander and out‐of‐hospital CPR for ≈20 minutes. On arrival at the ED, advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) protocols were followed, including placement of bilateral chest tubes and initiation of the massive transfusion protocol. Return of spontaneous circulation was achieved without a change of the Glasgow Coma Scale (GCS). Pupils remained fixed and dilated. Other pertinent findings of the physical exam include a distended abdomen with a negative focused assessment with sonography in trauma (FAST) exam and a right humeral deformity. After direct laryngeal intubation, an orogastric tube was placed and the patient was transferred to radiology for trauma computed tomography (Figures 1, 2, 3, and 4).
Figure 1.
Computed tomography (CT) sagittal view of endotracheal tube (ET) placement demonstrating orogastric tube tracking into spinal canal (arrow)
Figure 2.
Additional CT sagittal view of ET placement demonstrating orogastric tube tracking into spinal canal (arrow)
Figure 3.
2D Reformatted images of orogastric tube (arrow)
Figure 4.
Axial view of orogastric tube placement (arrow)
2. DIAGNOSIS
Type II/vertical craniocervical/atlanto‐occipital dissociation, with complete loss of alignment on the right side.
Atlas fracture with rotatory subluxation at the atlanto‐occipital articulations.
Prevertebral soft tissue hematoma with orogastric tube coursing through the prevertebral soft tissue and encircling the spinal canal.
Significant spinal cord injury.
Grade 2 liver laceration.
Bilateral vertebral artery injuries.
3. HOSPITAL COURSE
Following imaging, the patient was taken directly from radiology to the surgical intensive care unit (SICU). When the patient arrived, bleeding was noted from both the mouth and rectum. The orogastric tube was removed after neurosurgery consultation and oral maxillofacial surgery was consulted due to continued oral bleeding. Packing of the oral cavity was attempted with the goal of slowing retropharyngeal bleeding. When bleeding continued, the patient was taken to interventional radiology for further evaluation. Embolization of the retropharyngeal vasculature was attempted as well as an angiogram. During the procedure, it was noted that the patient had only retrograde flow through vertebral arteries and had no flow distal to the circle of Willis. Further treatment was deemed futile and the patient was returned to SICU. The patient's condition continued to deteriorate despite resuscitation efforts and progressed into pulseless electrical activity and ultimately asystole.
4. DISCUSSION
The patient sustained a spinal dissociation at the level of the skull and cervical spine as well as a fracture of the atlas. Atlanto‐occipital dislocation is present in 1% of cervical spine injuries and atlanto‐occipital dislocation has been reported to be the most common cervical spine injury directly related to motor vehicle accident fatalities with an incidence up to 35%.1, 2 During resuscitation efforts, the orogastric tube insertion inadvertently resulted in its placement into the spinal canal. Following extensive literature search for similar outcomes, no previously documented cases involving orogastric tube misplacement into the spinal canal could be located. Multiple documented cases of nasogastric tube misplacement into the intracranial space were noted including those following nasal surgery and in trauma patients. In one study by Spurrier et al (2008), 23 cases of intracranial nasogastric tube placement were documented. Of those 23 cases, 17 were trauma‐related and the 6 remaining cases were a mixture of pituitary adenoma, cribriform plate perforation or previous trans‐sphenoidal manipulation.3 In a single case report by Porras et al (1993), inadvertent intraspinal placement of a Foley catheter was the result of atlanto‐occipital dislocation. This, however, was following nasogastric tube placement and not orogastric tube placement.4 One final case study noted nasogastric tube placement into brain stem and spinal canal following endoscopic skull surgery.5
5. CONCLUSION
Although it is commonly understood that nasogastric tube placement following trauma or suspected basal skull fracture should be done with caution and is a relative contraindication, no similar recommendations exist for orogastric tubes. ATLS protocols recommend that in such cases of trauma where skull fractures are suspected or confirmed, orogastric tubes should be inserted instead.6 Literature searches yielded no previous cases of orogastric tube placement into the spinal canal and as such, no current recommendations of orogastric tube insertion following trauma could be located. Based on this experience and the understanding that atlanto‐occipital dislocation is the most common cervical spine injury directly related to motor vehicle accidents, the authors recommend that in such patients, an orogastric tube be placed under video or direct laryngeal guidance to prevent inadvertent misplacement.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
Baker RA, Baker S. Orogastric tube placement during trauma arrest. JACEP Open. 2020;1:642–644. 10.1002/emp2.12013
Supervising Editor: Michael Blaivas, MD, MBA.
Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
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