# Use of NPA on ALOC patient?



## TimRaven (Nov 2, 2015)

Hi, I got some problem on the timing of NPA for ALOC patient...

Last week we had a patient with suspect overdose, the pt was only responsive to very strong pain stimulation. Since the pt was supine on the floor, I attempted a NPA to protect her airway after checking facial trauma, but was rejected when pt attempted to pushed my hand away in the process.

Later I was told by my superior that my decision of NPA was inappropriate on this patient, and also told that I can't use NPA on a "responsive to pain" patient per California protocol.

Is this true? I should only use NPA on completely unresponsive patients? 
I remember in school yjr only contraindication of NPA was facial/head trauma.


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## EpiEMS (Nov 2, 2015)

I can't speak to your protocols, but typically, as an airway adjunct for the conscious/semi-conscious patient, the NPA is considered perfectly acceptable. In the context of an OD, no reason not to drop one, barring (again) facial trauma (though slight facial traima isn't an absolute contraindication that we have been told: http://m.emj.bmj.com/content/22/6/394.full).


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## SeeNoMore (Nov 2, 2015)

I don't know about California protocols but  that's not correct. You can use npas on pts who remain responsive to pain.


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## Akulahawk (Nov 2, 2015)

There is no statewide California protocol that I'm aware of. You use any airway adjunct on patients that have some kind of airway compromise. If the "responsive to pain" patient can't control their airway well, you use an airway adjunct.


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## TimRaven (Nov 3, 2015)

That's what I thought and taught, but my superior clearly doesn't agree. 
I should be more careful about their standard in the future...


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## SeeNoMore (Nov 3, 2015)

It's a tough situation. Your supervisor clearly needs some re-education but you also don't want to kick your own legs out from under you by seeming argumentative or arrogant. Perhaps you could respectfully show him/her some relevant information and ask whether there might be some misunderstanding? The sad truth is that many EMS providers practice a strange form of care based on superstition, "how it's always been done", and/or simple ignorance.


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## TimRaven (Nov 3, 2015)

I didn't plan to confront about this issue further anyway. I just want to know if I was mistaken on the airways criteria.


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## jwk (Nov 3, 2015)

Your superior is uninformed at best, and the protocol, if that is actually a protocol, is just plain stupid.  Stick anything in your nose - it's irritating as hell - but once it's there, it's not that bad.  Think of NG tubes that stay in for days on end. That's why NPAs can be used on conscious or semi conscious patients.  Unlike oral airways, they don't stimulate a gag reflex.


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## Underoath87 (Nov 15, 2015)

If the patient can lift their hand and pull out/block the NPA, that's a pretty good sign that they don't need it yet.  Did you try bagging without it?


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## Bullets (Nov 27, 2015)

Underoath87 said:


> If the patient can lift their hand and pull out/block the NPA, that's a pretty good sign that they don't need it yet.  Did you try bagging without it?



I disagree, just because they may have some motor response does not mean they can sufficiently protect their own airway. Any patient who cant protect their own airway should at least consider an NPA. We use the quite regularly in my service, it has become the frontline airway adjunct. the OPAs collect dust


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## Carlos Danger (Nov 27, 2015)

Bullets said:


> I disagree, just because they may have some motor response does not mean they can sufficiently protect their own airway. Any patient who cant protect their own airway should at least consider an NPA. We use the quite regularly in my service, it has become the frontline airway adjunct. the OPAs collect dust



An NPA provides no airway protection whatsoever - it simply provides a route for ventilation. If someone is exchanging air just fine, they don't need an NPA.


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## CALEMT (Nov 27, 2015)

TimRaven said:


> That's what I thought and taught, but my superior clearly doesn't agree.
> I should be more careful about their standard in the future...



Little late but check your county protocols? There's no California state wide protocol for anything. Protocols vary from county to county.


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## NYBLS (Nov 29, 2015)

Remi said:


> An NPA provides no airway protection whatsoever - it simply provides a route for ventilation. If someone is exchanging air just fine, they don't need an NPA.



Agreed. If this pt required airway protection then they should be intubated.


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## philslat (May 2, 2016)

Can you suction through the npa using a french catheter


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## Underoath87 (May 2, 2016)

philslat said:


> Can you suction through the npa using a french catheter



For what purpose?  Are you just trying to suction the nasal sinuses?


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## ExpatMedic0 (May 3, 2016)

I use NPA's a lot more than my coworkers do. Basically, if anyone who is semi-conscious or unconscious will easily accept one but still have a gag-reflex, I always try to drop an NPA on them. If they become combative or just resist the procedure strongly, then I do not go forward with it.


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## Carlos Danger (May 5, 2016)

philslat said:


> Can you suction through the npa using a french catheter


Sure, and its a great idea when the teeth are clenched.


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## Carlos Danger (May 5, 2016)

Most of my NPA's go in the mouth. Less stimulating than either an OPA or an NPA placed nasally.


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## MonkeyArrow (May 5, 2016)

Remi said:


> Most of my NPA's go in the mouth. Less stimulating than either an OPA or an NPA places nasally.


Can you elaborate?


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## Inspir (May 6, 2016)

Standard approach for ETOH patients. NPA x 2 + OPA. Patent the **** out of that airway!


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## NomadicMedic (May 6, 2016)

Inspir said:


> Standard approach for ETOH patients. NPA x 2 + OPA. Patent the **** out of that airway!



PLEASE tell me you're kidding.


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## Carlos Danger (May 6, 2016)

MonkeyArrow said:


> Can you elaborate?


Very often in moderately sedated patients there is some level of upper airway obstruction in the supine position. They may not tolerate an OPA or even an NPA without adding additional sedation. In those cases, a soft NPA inserted gently along the curvature of the tongue will often work nicely. There's more than one hole you can stick that thing in.

Probably not all that applicable to the prehospital setting, but maybe.


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## CALEMT (May 6, 2016)

Remi said:


> There's more that one hole you can stick that thing in.



Giggity.


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## exodus (May 6, 2016)

Remi said:


> Very often in moderately sedated patients there is some level of upper airway obstruction in the supine position. They may not tolerate an OPA or even an NPA without adding additional sedation. In those cases, a soft NPA inserted gently along the curvature of the tongue will often work nicely. There's more than one hole you can stick that thing in.
> 
> Probably not all that applicable to the prehospital setting, but maybe.


 C-Collars work good as well to keep the airway anatomical.  How do you secure the NPA?


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## Carlos Danger (May 6, 2016)

exodus said:


> C-Collars work good as well to keep the airway anatomical.  How do you secure the NPA?


C-collars tend to worsen passive airway obstruction, IME.

No securing needed. They stay put.


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## Tigger (May 6, 2016)

Underoath87 said:


> If the patient can lift their hand and pull out/block the NPA, that's a pretty good sign that they don't need it yet.  Did you try bagging without it?


If the patient needs to be bagged, how will an NPA be a negative?


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## Underoath87 (May 6, 2016)

Tigger said:


> If the patient needs to be bagged, how will an NPA be a negative?



My point was that the pt probably didn't need to be bagged in the first place if they still had the ability to fight off the NPA.
And if they're still responsive to pain, try bagging them first without an airway adjunct (since having a foreign object shoved up one's nose hurts like hell).


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## Tigger (May 6, 2016)

Underoath87 said:


> My point was that the pt probably didn't need to be bagged in the first place if they still had the ability to fight off the NPA.
> And if they're still responsive to pain, try bagging them first without an airway adjunct (since having a foreign object shoved up one's nose hurts like hell).


Certainly possible, but I still maintain that using a BVM is hard enough, help yourself and use an adjunct or three.


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## OCemt86 (Jul 4, 2016)

What were the patients vitals? Did you have reason to believe the airway would become compromised? 

What county in CA were you in? What's the protocol. 

Here in California, pretty much anything aside from taking vitals, they're going to want you to upgrade to ALS if you're not already. 

Kern county is about the only county with an actual expanded not "expanded" scope of practice, that let's the EMT utilize stuff you were taught how to do. Most other counties it's pretty much, "oh you took a dstick on patient? Upgrade." 

Knowing most county EMSA in CA though, if you're going to use an airway adjunct as an EMT without a medic present asking you to do it for them, the patient pretty much has to be a gcs of 3.


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