Is nasal placement of a Nasogastric (NG) tube safe in a patient with traumatic brain injury if the Computed Tomography (CT) scan of the brain does not show a cribriform plate fracture?

Nasogastric Tube Placement in Traumatic Brain Injury Without Cribriform Plate Fracture on CT

Even when CT brain does not show a cribriform plate fracture, you should use an orogastric tube instead of a nasogastric tube in traumatic brain injury patients, as CT has limited sensitivity for detecting all skull base fractures and the consequences of intracranial tube misplacement are catastrophic.

Primary Recommendation

• Use orogastric tube placement rather than nasogastric tube placement in all traumatic brain injury patients, regardless of CT findings 1, 2
• The Advanced Trauma Life Support protocol specifically recommends orogastric tubes over nasogastric tubes in patients with suspected or confirmed basal skull fractures 1
• Multiple case reports document intracranial nasogastric tube placement associated with patient death, even when the causal relationship remains unclear 1

Why CT Findings Are Insufficient to Rule Out Risk

CT Limitations in Detecting Skull Base Fractures

• CT has limited sensitivity for detecting all skull base fractures, particularly subtle or nondisplaced fractures 3
• Thin-section multidetector CT with bone windows is required for optimal detection, but even this may miss subtle injuries 3
• The cribriform plate is a thin, delicate structure that can be fractured without obvious CT findings 3

Associated High-Risk Injuries Often Present

• Fractures through the medial frontal sinus floor typically involve the cribriform plate and fovea ethmoidalis, which may result in CSF leak 3
• 56% to 87% of patients with frontal sinus fractures have craniofacial injuries 3
• Additional facial fractures are present in 75% of cases with frontal bone fractures 3

Mechanism of Intracranial Tube Misplacement

• Intracranial placement occurs through either passage through a traumatic defect in the cribriform plate or direct penetration through an intact cribriform plate by an improperly passed rigid tube 4
• The lamina cribrosa of the ethmoid bone provides a pathway for inadvertent intracranial placement 5
• In combative, semicomatose, or comatose patients, oral placement is preferable to nasogastric placement 4

Clinical Risk Factors That Should Trigger Orogastric Route

Even without visible cribriform fracture on CT, use orogastric tube if any of these are present:

• Any traumatic brain injury with altered consciousness 4, 1
• Signs of skull base fracture (Battle's sign, raccoon eyes, CSF rhinorrhea/otorrhea) 1
• LeFort II or III type facial fractures 3
• Fractures of the basal skull 3
• Soft tissue lesions at the neck 3
• Focal neurological deficits not explained by brain imaging 3

Consequences of Intracranial Misplacement

• High morbidity and mortality associated with intracranial tube placement 6
• Patient death has been documented in multiple case reports 1, 5
• One reported case resulted in death on day 2 of admission despite tube removal 5
• Even when tubes are removed quickly through the nose, the risk of neurologic complications remains 6

Common Pitfalls to Avoid

• Do not rely solely on CT brain to exclude skull base fractures - CT has limited sensitivity for subtle fractures 3
• Do not assume an "intact" cribriform plate on CT means safe nasogastric passage - direct penetration through intact bone has been reported 4
• Do not delay switching to orogastric route if any doubt exists - the consequences of intracranial placement are catastrophic 1, 5
• Do not use nasogastric tubes in combative or semicomatose patients - inability to cooperate increases misplacement risk 4

Practical Implementation

• Place orogastric tubes in all moderate to severe TBI patients (those requiring neurosurgical consultation, ICU admission, or with GCS < 13) 3, 7
• If facial trauma prevents orogastric placement, consider delaying enteral access until surgical consultation 1
• Document the decision-making process and route chosen in the medical record 1
• Confirm tube placement with chest X-ray before use, regardless of route 2