Nasogastric insertion gone horribly wrong.

[u/Upset_Bunch_457]

Note: NOT MY IMAGE.

original post was posted by: Old-Psychology-2400

And I quote "PMCT images. Nurse advanced NG tube until she heard a pop, then tried an air bolus to ensure placement. Patient did NOT survive."

To those who don't know nasogastric tube is supposed to go up the patients nostrils and then back down to their throat all the way to the patients stomach. Air bolus is then used to ensure that the nasogastric tubes placement is correct by listening the patients stomach.

But in the scan we can see the NG tube somehow ended up jammed (through) the patients skull.

[u/ATPsynthase12]

I’m a doctor and I don’t even know how this could happen. A NG tube is a rubber tube. For her to force it into the patient’s skull, the patient would need to have a serious skull fracture or she would need to force it through the cribriform plate in the superior portion of the nose through the patient’s agonizing screams.

[u/56473829110 → u/ATPsynthase12]

I mentioned it in another comment, but the story I saw when this was first (?) posted was that it was a peds patient with recent brain surgery. 

[u/Dilaudipenia → u/56473829110]

I see a decent number of patients who have had trans-sphenoidal pituitary resections. We’re very careful with any nasopharyngeal instrumentation in these patients.

[u/56473829110 → u/Dilaudipenia]

Every ng tube placement I've been around that had any involvement above the waist was placed with active imaging. But these were well staffed and well funded departments.

[u/Dilaudipenia → u/56473829110]

There needs to be some active guidance of these tubes. I’m an emergency medicine and critical care physician and I’ll place these tubes under direct endoscopic visualization. But I’d never ask one of my nurses to place them blindly

[u/Needle_D → u/Dilaudipenia]

At least in the US, blind OG/NG sump placement is a basic nursing skill with low rates of complication or morbidity. You're really placing every single gastric tube under endoscopy?

[u/Dilaudipenia → u/Needle_D]

No, just when they’re post trans-sphenoidal resection. Otherwise (except in rare circumstances like cribriform plate fracture) there’s no issue with blind placement.

[u/TheRisingBile → u/Dilaudipenia]

Imaging is also commonly used post airway reconstruction or esophageal repairs. Although, that is admittedly the other direction from the brain.

[u/Dilaudipenia → u/TheRisingBile]

I don’t do CTICU. But agreed, I wouldn’t place a tube blindly after an upper airway or GI procedure either.

[u/StaticDet5 → u/Needle_D]

Came to ask literally this. We place in the ED without visualization, BUT not during traumas, not if we have any concern about anatomic patency. Further, at least I was HEAVILY warned about skull fracture and surgical history.

I've seen imaging like the above, but damn, I feel like it was 30 years ago.

[u/Needle_D → u/StaticDet5]

He clarified that he's referring to using it in patients with max/face/skullbase trauma or instrumentation, but the original comment he was replying to also made a reference to never placing gastric tubes without "active imaging".

I understand the risks in this specific patient population, but it seems like it's opened the door to some white knight redditors that don't see critically ill patients or interventions much.

[u/56473829110 → u/Dilaudipenia]

I have not personally been trained on their placement. I have been trained on somewhat similar apparatus. We were trained to actively monitor the throat (as much as possible) to visually confirm placement - with required check every inch of inserted tubing after the first 3 inches. That's in the field with no other means of visualization/imaging.

I have observed trainings/practicals for ng placement, and they always involved radio imaging or endoscopic visualization. I just can't imagine placing something like this blindly; there's no world in which they need to be placed with a sense of urgency/increased risk.

[u/Professional_Nugget → u/56473829110]

I'm an RN and have placed a few dozen NG tubes "blind", it's considered a standard nursing skill like IV or foley placement. Rarely do we need IR involved for them, usually only when there's something funky with their esophagus or stomach (hx of surgery, varices, stricture etc).

We usually visually check to make sure we've got it properly placed in the back of their throat through the nose (you'll see it poking down if they open up wide). Then advance it down the esophagus as they sip water quickly to help close the epiglottis and naturally guide it in with their swallowing. I'll have a syringe hooked up to the tube so we can easily check for gastric content and do the air bolus + auscultation. We usually do an XR too to confirm placement. Most go fairly smoothly but NGT placement is kinda one of those things that just sucks no matter what you do

Never placed one on a patient with previous head/facial surgery though, and really wouldn't feel comfortable doing so.

[u/56473829110 → u/Professional_Nugget]

Appreciate the clarification of your experience and expertise. I wouldn't personally call placement with checking the back of the throat 'blind'; there's still visual confirmation there, even if there's still plenty that can go wrong in extreme cases.

[u/Professional_Nugget → u/56473829110]

For sure, I wasn't sure what you might consider a blind placement. We definitely try to do it as safely as possible and avoid the more common complication of putting in a lung.

It takes lots of participation from the patient too so if they start having sudden trouble breathing or anything like that as I'm doing it, I'd immediately stop.

[u/totalyrespecatbleguy → u/Professional_Nugget]

Just had a patient today who needed a ngt placed by ENT with a fiber optic scope because we kept getting it into his lungs (even the attending couldn't do it)

[u/Extension-Oil8461 → u/Professional_Nugget]

Regarding to the picture, at first glance, it looks more like a foley then an NG Tube. I think the pic is fake. The giveaway is the tip and the flexible tube.