Chapter 47

Nasogastric intubation is one of the common procedures performed in Emergency Departments in the United States.1 Its use as a conduit into the stomach was first popularized in the early twentieth century mainly through the efforts of Levin. Since then, clinicians have studied its use and have proposed methods to improve the ease with which the tube is inserted as well as ways to diminish the incidence of potentially lethal complications. A nasogastric tube is often placed in patients who have a bowel obstruction, intractable nausea and vomiting, intoxication, significant trauma, and upper gastrointestinal bleeding. The procedure is rapid, simple, and straightforward.

The nasal cavity is lined by the very vascular nasal mucosa. The medial wall of the nasal cavity is composed of the septum. The lateral wall of the nasal cavity is covered by the turbinates. The posterior nasal cavities are continuous with the nasopharynx that develops into the posterior oropharynx as you move caudally (Figure 47-1). The oropharynx continues inferiorly as the esophagus that enters the stomach below the diaphragm.2

FIGURE 47-1

Basic anatomy of the path of the nasogastric tube.

The placement of a nasogastric tube in children is often difficult. Their large tonsils and adenoids may hinder the passage of the nasogastric tube. These tissues are soft, easily injured, and may bleed as the nasogastric tube is passed. The tongue, large by comparison with adults, may push into the oropharynx and impede passage of the nasogastric tube. Their nostrils and nasal passage are quite small and limit the size of nasogastric tube that may be passed.

Nasogastric intubation may be performed for diagnostic or therapeutic indications. A nasogastric tube may be inserted to instill air into the stomach to assess for an intraperitoneal perforation. It is used to evaluate the presence, rapidity, and volume of an upper gastrointestinal hemorrhage. Gastric fluid and contents may be aspirated for laboratory analysis. It may also be placed to visualize the stomach on chest radiography to assess for a diaphragmatic hernia. A nasogastric tube is placed in patients for medication administration, relief of a bowel obstruction, treatment of recurrent vomiting, and to perform gastric lavage. They are placed preoperatively, postintubation, prior to a diagnostic peritoneal lavage, or prior to a pericardiocentesis to decompress the stomach.

Absolute contraindications do not exist for nasogastric tube placement. The relative contraindications are geared toward predicting which patients are more likely to experience complications and which patients are likely to have misplaced tubes. Insertion of a nasogastric tube should be avoided, unless necessary, in the patient with midface trauma. Intubation through the nasal cavity can result in the nasogastric tube being misdirected blindly into the respiratory tract or the rare perforation through the thin cribriform plate of the ethmoid bone and into the brain. Patients with facial trauma are best ...

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