Caution during endotracheal suctioning in case of skull base fractures!

Cerebral exteriorization through the cribriform plate during routine endotracheal suctioning (ETS) in a coughing patient without sedation with multiple complex skull base fracture; this case has never been reported in the literature.

We report the case of a polytrauma patient admitted in our ICU with severe traumatic brain injury (TBI) and multiple complex skull base fractures. After 48 hours of neurocritical care and stable neuromonitoring parameters, sedation was stopped for neurological assessment. During this period and while routine ETS was being performed, brain herniation with exteriorization through the nose occurred with a concomitant ICP elevation.

ETS can induce the coughing reflex and provoke a rise in ICP. It is a simple routine procedure that should be performed with great precautions in order to avoid iatrogenic complications, particularly in patients with skull base fractures, such as brain herniation as described in our patient.