# Clearing up OPA and NPA use



## crazyskiier68 (Dec 3, 2009)

Trying to get a little more clarity- If you are assessing ABC's- A first of course
If the patient is just "out" syncope... but clear airway/breathing etc- You would not insert any type of airway correct? I guess I'm trying to figure out how to really identify a "patent" airway.  If they are unresponsive and can tolerate the OPA- I get that- but how do you determine if they are completely "out" so to speak- what tips or advice can you give?


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## CountryEMT-bGurl (Dec 3, 2009)

If you have an unresponsive person, you put the OPA in and if they start to gag then remove it!  Then consider putting in a NPA. But never but in a NPA if there is any indication of facial trauma.
This is what I was taught, someone chime in if I am wrong.


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## VentMedic (Dec 3, 2009)

If the patient has a clear airway with no snoring, no increased struggle to breathe and you hear good breath sounds thoughout with good chest rise, you do not need to use an OPA or NPA.


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## CountryEMT-bGurl (Dec 3, 2009)

VentMedic said:


> If the patient has a clear airway with no snoring, no increased struggle to breathe and you hear good breath sounds thoughout with good chest rise, you do not need to use an OPA or NPA.



Yes, my answer was for how to determine if your pt. was completely "out" enough to use a OPA!

Am I correct VentMedic, or no?


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## wyoskibum (Dec 3, 2009)

CountryEMT-bGurl said:


> If you have an unresponsive person, you put the OPA in and if they start to gag then remove it!  Then consider putting in a NPA. But never but in a NPA if there is any indication of facial trauma.
> This is what I was taught, someone chime in if I am wrong.



Let's not forget about AVPU.  If they respond to verbal or painful stimuli, there is a really good chance that the gag reflex is intact.  I usually don't attempt an OPA unless there is no reaction to my most painful stimuli.


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## CountryEMT-bGurl (Dec 3, 2009)

wyoskibum said:


> Let's not forget about AVPU.  If they respond to verbal or painful stimuli, there is a really good chance that the gag reflex is intact.  I usually don't attempt an OPA unless there is no reaction to my most painful stimuli.



*Thanks, AVPU just passed my mind. *


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## medicdan (Dec 3, 2009)

Inserting an OPA or NPA is certainly a noxious stimulant, and in many cases an inhumane way to measure level of responsiveness. Please dont try to shove them down the airway of every AMS you see, it ends poorly for all involved.


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## Shishkabob (Dec 3, 2009)

Just as an FYI, most times a syncopal episode is self correcting.  Pretty soon after a patient becomes horizontal on the floor they'll start regaining conciousness as blood flow becomes normal in the head again. 

If your pt is uncincious long enough to make you consider an airway adjunct, there's probably something more going on than just a syncopal episode. 




As for what to do, do the least invasive technique tgat works.  If all you need to maintain latency is a head tilt/chin lift, then that's all you need to do.


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## zmedic (Dec 3, 2009)

I'm sorta a fan on starting with the NPA. 1. It doesn't make them gag. And 2. sometimes it wakes them up even if they don't respond to sternal nuggie.


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## VentMedic (Dec 3, 2009)

Just remember to have suction nearby when using either of these devices.  Blood aspiration from the NPA is not good and neither is the vomit from an OPA or other objects and secretions that might be in the oral cavity.   The aspiration may do more harm than the initial complaint.


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## rescue99 (Dec 3, 2009)

zmedic said:


> I'm sorta a fan on starting with the NPA. 1. It doesn't make them gag. And 2. sometimes it wakes them up even if they don't respond to sternal nuggie.



Yep, a gently placed NPA for an unconcious patient is appropriate if AVPU indicates the need. NPA is pretty non threatening and highly underused IMO.


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## MrBrown (Dec 3, 2009)

Your primary survey should include AVPU/GCS anyway so that should give you an indication of how unconscious the patient is!

Remember the most simple way of ensuring a patent airway is with head tilt chin lift.  An airway that is open and patent will have clear and equal breath sounds, no snoring, stridor or signs of cyanosis and good chest rise.

If you have all those then there is no need to insert an airway.


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## imurphy (Dec 3, 2009)

Holding in an NPA with duck tape is not advisable


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## Shishkabob (Dec 3, 2009)

What about duct tape?


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## AnthonyTheEmt (Dec 3, 2009)

CountryEMT-bGurl said:


> If you have an unresponsive person, you put the OPA in and if they start to gag then remove it!  Then consider putting in a NPA. But never but in a NPA if there is any indication of facial trauma.
> This is what I was taught, someone chime in if I am wrong.




You're exactly right. If someone has sustained facial trauma and you try to insert an NPA, you could actually insert it into the cranial cavity and then you causing more harm than good


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## zmedic (Dec 3, 2009)

That's true and the protocols, but I hear it's a bit of an urban myth. I was told there has never been a documented case of an airway being put into the brain. Again, you should follow the protocols and not put in the NPA when you suspect skull fracture, but just keep in mind there isn't really good evidence for it.


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## rescue99 (Dec 3, 2009)

zmedic said:


> That's true and the protocols, but I hear it's a bit of an urban myth. I was told there has never been a documented case of an airway being put into the brain. Again, you should follow the protocols and not put in the NPA when you suspect skull fracture, but just keep in mind there isn't really good evidence for it.



No so..I ran a call on a massive head trauma where FD had already placed a NPA. That was definately brain tissue oozing up out of the adjunct, or else the guy ate oatmeal for breakfast. Documentation was so much fun. :wacko:


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## VentMedic (Dec 3, 2009)

zmedic said:


> That's true and the protocols, but I hear it's a bit of an urban myth. I was told there has never been a documented case of an airway being put into the brain.


 
It is not entirely a myth. However it is rare probably because most do adhere to their protocols to not nasally insert a tube be it NPA, NTI or NGT. I personally have seen a couple patients with the brain intubated. One was a pediatric with an NGT...fatal. Actually both cases were fatal.  I have also taken care of a couple cases of pneumocephalus from CPAP which was placed on TBI patients.

Here is one complete with pictures:
*Complication from a Nasopharyngeal Airway in a Patient with a Basilar Skull Fracture*
http://journals.lww.com/anesthesiol...ion_from_a_Nasopharyngeal_Airway_in_a.26.aspx

*Intracranial Malposition of Nasopharyngeal Airway*

*Schade, Karen RN, CCRN, TNC; Borzotta, Anthony MD, FACS; Michaels, and Andrew MD, MPH*

The Journal of Trauma: Injury, Infection, and Critical Care : 
November 2000 - Volume 49 - Issue 5 - pp 967-968
Case Reports


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## RyanMidd (Dec 4, 2009)

And remember, kids:

If they're not up in 60 seconds, it's not syncope. Just as if the symptoms do not clear up within 24 hours, its not a stroke, it is a TIA. I guess its not the disease process that garners the diagnosis so much as the length those symptoms persist.

/troll


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## reaper (Dec 4, 2009)

Got that one backwards.


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## zmedic (Dec 4, 2009)

Thanks for the link, guess there have been documented cases. But again, if they don't have signs of head trauma I say hit the NPA.


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## gamma6 (Dec 16, 2009)

Linuss said:


> Just as an FYI, most times a syncopal episode is self correcting.  Pretty soon after a patient becomes horizontal on the floor they'll start regaining conciousness as blood flow becomes normal in the head again.
> 
> If your pt is uncincious long enough to make you consider an airway adjunct, there's probably something more going on than just a syncopal episode.
> 
> ...


so true......


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