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Emerg Med J. 2007 April; 24(4): 311.
PMCID: PMC2658253

Intracranial placement of a nasopharyngeal airway in a gun shot victim

Further to the review by Roberts et al1 and the letter by Ellis et al,2 we report another case of intracranial placement of a nasopharyngeal airway.

The patient was an adult who had been shot in the head and dumped by the roadside in Baghdad in 2006. The patient was found by a military patrol who gave first aid. The medic on scene noted that the patient was deeply unconscious, had facial injuries and an obstructed airway. A nasopharyngeal airway was placed and rapid transfer undertaken to the US combat support hospital (CSH) in the international zone.

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

The emergency medicine consultant 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 difficult to assess in the field.

An internet search for intracranial placement of nasopharyngeal airways produced the reports by Muzzi et al3 and Schade et al4 (as referenced by Roberts1 ) and an additional case report by Martin et al.5

The report by Martin et al 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 Advanced Trauma and Life Support teaching6 builds on the work of Butler et al7 and teaches that clinical care has to be modified according to the threat environment (Battlefield Advanced Trauma and Life Support (BATLS) is the UK military derivation of Advanced Trauma and Life Support).

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


1. Roberts K, Whallcy H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J 2005. 22394–396.396 [PMC free article] [PubMed]
2. Ellis D Y, Lambert C, Shirley P. Intracranial placements of nasopharyngeal airways: is it all that rare? Emerg Med J 2006. 23661 [PMC free article] [PubMed]
3. Muzzi D A, Loasso T J, Cucchiara R F. et al Complication from a nasopharyngeal airway in a patient with a basilar skull fracture. Anaesthesiology 1991. 74366–368.368 [PubMed]
4. Schade K, Borzotta A, Michaels A. Intracranial malposition of nasopharyngeal airwary. J Trauma 2000. 49967–968.968 [PubMed]
5. Martin J E, Mehta R, Aarabi B. et al Intracranial insertion of a nasopharyngeal airway in a patient with craniofacial trauma. Military Medicine 2004. 169496–497.497 [PubMed]
6. BATLS 2005 Joint Service Publication 570. First seven chapters published as Supplement to Journal of the Royal Army Medical Corps 2006, vol 152 no 2
7. Butler F K, Hagmann J, Butler E G. Tactical Combat Care in Special Operations. Military Medicine 1996. 161supplement 1 [PubMed]

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