From the Guidelines
Nasopharyngeal airways (NPAs) should be used with caution in head trauma patients, as they are generally acceptable when an oropharyngeal airway is difficult to place or not tolerated, but contraindicated in patients with suspected basilar skull fractures or significant facial trauma. The primary concern with using NPAs in head trauma patients is the risk of inadvertent intracranial placement through a fractured cribriform plate, which could lead to serious complications including cerebrospinal fluid leakage or direct brain injury 1. When using an NPA in appropriate head trauma cases, it is essential to ensure proper sizing, typically based on the distance from the nostril to the tragus of the ear, lubricate adequately with water-soluble lubricant, and insert gently along the floor of the nasal cavity. Some key considerations for airway management in head trauma patients include:
- Indications for tracheal intubation, such as a Glasgow Coma Scale (GCS) score of 8 or less, significantly deteriorating conscious level, loss of protective laryngeal reflexes, and hypercarbia 1
- The importance of controlling ventilation and monitoring end-tidal CO2 levels in intubated patients to maintain optimal cerebral perfusion pressure 1
- The potential benefits and limitations of using transcranial Doppler to assess the severity of traumatic brain injury 1 It is crucial to weigh the potential benefits of using an NPA against the risks and to be prepared to remove the NPA and consider alternative airway management if complications arise. Always monitor for bleeding after insertion, which can occur due to the vascularity of the nasal mucosa. In general, the use of NPAs in head trauma patients requires careful consideration of the individual patient's condition and the potential risks and benefits of this intervention.
From the Research
Use of NPAs in Head Trauma
- The use of non-pharmacological agents (NPAs) in head trauma is not directly addressed in the provided studies, but some studies discuss the use of non-opioid analgesics and multimodal pain management in trauma patients 2, 3.
- A study on acute pain relief in children with musculoskeletal trauma found that ibuprofen provided the best analgesia among the three study medications, including acetaminophen and codeine 4.
- Another study reviewed the properties of various non-opioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, α2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics, and encouraged pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia 3.
- A systematic review on the effect of opioids on cerebral physiology in traumatic brain injury found that opioids can have either no effect or an increase in intracranial pressure (ICP) with associated decreases in cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) 5.
Non-Opioid Analgesics in Head Trauma
- Non-opioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs, can be used as adjuncts or alternatives to opioids in trauma patients 2, 3.
- Ketamine, a non-opioid analgesic, has been shown to have a protective effect against ischemic and traumatic brain damage in animal studies, but its use in head trauma patients is still being studied 6.
- The choice of non-opioid agents should be based on patient comorbidities, hemodynamic stability, and the agents' respective adverse effect profiles 3.
Multimodal Pain Management in Head Trauma
- Multimodal pain management, which involves the use of multiple non-pharmacological and pharmacological interventions, can be effective in reducing pain and opioid use in trauma patients 2, 3.
- A multidisciplinary plan for management of pain should be formulated during transitions of care, and pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors 3.