What is the initial recommended method of feeding for a patient in a deep coma following head trauma?

Initial Feeding Method for a Patient in Deep Coma Following Head Trauma

Nasogastric tube (NGT) feeding is the recommended initial method for providing nutrition to a patient in deep coma for 5 days following head trauma. 1

Rationale for Nasogastric Tube Feeding

• Early enteral nutrition (within 24 hours after trauma) is recommended for patients with head injury who cannot maintain adequate oral intake, as it reduces infectious complications and improves outcomes 1
• For patients in coma following head trauma, nasogastric tube feeding represents the least invasive and most appropriate initial approach for enteral nutrition 1
• Small diameter nasogastric feeding tubes (8 French) should be used to minimize the risk of internal pressure sores 1
• Nasogastric tube feeding allows for early nutritional support while maintaining the option to reassess the patient's condition and prognosis before committing to more invasive feeding methods 1

Timing of Initiation

• Tube feeding should be initiated within 24 hours after trauma for patients who cannot maintain oral intake 1
• Starting with a low flow rate (10-20 ml/h) is recommended due to limited intestinal tolerance in the acute phase 1
• It may take 5-7 days to reach the target nutritional intake, which is acceptable and not considered harmful 1

Why Not Other Options Initially?

• Gastrostomy (PEG): While PEG may be superior for long-term feeding (>14 days), it is not recommended as the initial feeding method in the acute phase of head trauma 1

  • PEG should be considered only after the initial phase (usually after 1 week) if prolonged artificial nutrition is anticipated 1
  • For mechanically ventilated patients who will likely require prolonged feeding, early PEG (within 1 week) may be considered due to lower rates of ventilator-associated pneumonia 1

• Peripheral or Central Line (Parenteral Nutrition): Enteral nutrition is preferred over parenteral nutrition whenever the gastrointestinal tract is functional 1

  • Parenteral nutrition should only be considered if enteral feeding is contraindicated or if energy needs cannot be met (<60% of caloric requirements) via the enteral route 1

• Nothing per oral, only IV fluids: This approach is inadequate for meeting nutritional needs in a comatose patient and would lead to malnutrition 1, 2

When to Consider Transitioning to PEG

• If nasogastric tube is repeatedly dislodged or not tolerated by the patient 1
• If enteral nutrition is anticipated to be needed for more than 14 days 1
• For mechanically ventilated patients requiring prolonged artificial nutrition 1
• A study comparing PEG vs. NGT in long-term coma patients showed that PEG feeding was associated with lower incidence of pulmonary infection (23.3% vs 37.8%) 3

Practical Considerations

• Verify correct placement of the nasogastric tube before feeding (via x-ray, aspiration of gastric content, or measurement of gastric pH) 1
• Monitor for common complications such as tube dislodgement, blockage, or aspiration 4
• Reassess the nutritional status and need for enteral nutrition regularly 1
• If the nasogastric tube is repeatedly removed accidentally, a nasal loop/bridle may be applied to secure it 1

Caution

• Avoid starting enteral nutrition too early (within first 3 days) in comatose stroke patients as it may not be nutritionally beneficial, though this differs from trauma patients where early feeding is recommended 2
• For patients with uncertain prognosis, the less invasive nasogastric tube is more appropriate as a first step before considering more permanent solutions 1
• The indication for artificial nutrition should be reassessed daily, particularly in patients with unfavorable prognosis 1