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Intracranial penetration during attempted nasogastric intubation is a rare, usually lethal, but avoidable complication. Such incidents are associated with facial and basilar skull fractures, acute neurologic deterioration, and litigation. We report two such incidents and the successful surgical procedure which utilized craniotomies positioned such that the nasogastric tubing could be removed in small, straight segments. The tubing in each case was removed without increasing the neurologic deficit, and the patients made an acceptable recovery considering their premorbid status.

One hundred thirty-nine pediatric blunt trauma patients 12 years of age or less were cared for using a protocol designed to identify which patients require aggressive surgical therapy and those who can be managed nonoperatively. Sixteen patients (average MISS score, 33) failed to respond to an estimated 20 cc per kilogram of crystalloid fluid resuscitation. Fifteen died, a mortality rate of 94%. One hundred twenty-three patients (average MISS score, 11) responded to less than or equal to 20 cc crystalloid fluid per kilogram with return of normal blood pressure, pulse rate, and nail bed capillary refill. Six died, a mortality rate of 5%, all from central nervous system injuries. Sixty-seven of these patients underwent ultrasound examination for suspected intra-abdominal injuries. Seventeen studies were positive. There were two complications (12%), but all 17 patients in this group were successfully managed nonoperatively. Our data suggest that quantitative crystalloid fluid resuscitation can identify pediatric blunt trauma patients suitable for nonoperative management and that ultrasound is a reliable tool for assessing intra-abdominal injury.