# OPA or NPA?



## MedicDelta (Oct 26, 2014)

Hey guys, just wondering what you go to first for an unresponsive patient who has no facial trauma. Do you attempt an OPA first and if there's a gag reflux go to an NPA? Or do some of you just go straight to an NPA? The way I was taught was to try an OPA first and then if there is a gag reflux present attempt to insert an NPA. Honestly, I can't remember why or if we were even taught why. I'm guessing it has to do with the fact that NPAs may not protect the patient from aspiration or the fact that it's more dangerous to use? I don't know, but that's how I was taught. What were you guys taught, and do you do it that way or differently?


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## DesertMedic66 (Oct 26, 2014)

I'll go for an OPA first. It does a better job at holding the tongue out of the way. However it offers zero protection from aspiration. 

If the patient accepts the OPA then the patient is pretty much going to get intubated (unless there is an easily reversible cause for the ALOC). 

If the patient has a gag reflex then I'll probably toss in a NPA.


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## Tigger (Oct 26, 2014)

OPAs go in on cardiac arrests. Other calls its more discretionary. Obviously if they are trismused we will not be using an OPA. Overdose? probably an NPA in case they wake up on their own.


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## NomadicMedic (Oct 26, 2014)

An NPA for an unresponsive medical patient (which usually comes out after the Narcan goes in) 

A patient being actively bagged without a gag gets 2 NPAs and a OPA... usually quickly followed by a tube.


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## Akulahawk (Oct 26, 2014)

If I determine that the airway is actually compromised, sometimes I'll go with an OPA. Sometimes I'll go with an NPA. When I use an NPA, it's because I think there's a good chance the patient may wake up or if I can't use an OPA. First thing done... jaw-thrust. While getting into position to do that, I can assess the pupils, check for trismus...


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## Brandon O (Oct 26, 2014)

I wouldn't stick in an OPA unless you're pretty sure there's no gag reflex. Doing them "empirically" on everyone is a good way to cause vomiting and a much bigger airway problem.


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## MedicDelta (Oct 27, 2014)

DesertEMT66 said:


> I'll go for an OPA first. It does a better job at holding the tongue out of the way. However it offers zero protection from aspiration.
> 
> If the patient accepts the OPA then the patient is pretty much going to get intubated (unless there is an easily reversible cause for the ALOC).
> 
> If the patient has a gag reflex then I'll probably toss in a NPA.


Interesting, thanks for the input


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## MedicDelta (Oct 27, 2014)

DEmedic said:


> An NPA for an unresponsive medical patient (which usually comes out after the Narcan goes in)
> 
> A patient being actively bagged without a gag gets 2 NPAs and a OPA... usually quickly followed by a tube.


2 NPAs? I've never heard of that


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## OnceAnEMT (Oct 27, 2014)

MedicDelta said:


> 2 NPAs? I've never heard of that



I don't think its textbook, but its definitely real world.


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## NomadicMedic (Oct 27, 2014)

It's most decidedly real world.


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## JamesW (Nov 23, 2014)

As I was trained, you always try for an OPA first, then NPA if the OPA doesn't work.


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## NomadicMedic (Nov 23, 2014)

JamesW said:


> As I was trained, you always try for an OPA first, then NPA if the OPA doesn't work.



Uhh, that's just wrong. Use the adjunct that is appropriate for the presentation.


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## EMT11KDL (Nov 26, 2014)

What is the reason for putting in a NPA or OPA.  Is the airway compromised? If my patient is breathing-unresponsive, most of the time I will drop an NPA, if I am going to have to bag the patient, than an OPA.  Also OPA if my patient has snoring respiration or if i have had to do a jaw thrust or head tilt chin lift to open the airway so the patients can breath on his own.  (As long as there is no gag reflex) 

It is a case by case basis on which one I use first.


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## COtoWestAfricaMEDIC (Nov 27, 2014)

NPA to check for responsiveness on a possible drunk case to see if they are faking or if you do not stay awake on me.


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## Handsome Robb (Nov 27, 2014)

COtoWestAfricaMEDIC said:


> NPA to check for responsiveness on a possible drunk case to see if they are faking or if you do not stay awake on me.



That's punitive medicine and absolutely inappropriate.


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## COtoWestAfricaMEDIC (Nov 27, 2014)

robb, meant to be a joke.


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## Handsome Robb (Nov 27, 2014)

Sorry, my sarcasm meter sucks late at night.


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## COtoWestAfricaMEDIC (Nov 27, 2014)

That's one thing that sucks about texting, typing or interacting in forums like this as you can't tell if some on is for real or is joking around. I guess I can start using the simile face deals.


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## EMT11KDL (Nov 27, 2014)

COtoWestAfricaMEDIC said:


> That's one thing that sucks about texting, typing or interacting in forums like this as you can't tell if some on is for real or is joking around. I guess I can start using the simile face deals.


The smile faces do help some regarding that lol


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## NomadicMedic (Nov 27, 2014)

COtoWestAfricaMEDIC said:


> That's one thing that sucks about texting, typing or interacting in forums like this as you can't tell if some on is for real or is joking around. I guess I can start using the simile face deals.




...or, post something funny?


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## usalsfyre (Nov 28, 2014)

Handsome Robb said:


> That's punitive medicine and absolutely inappropriate.


Eh....it's actually mostly indicated, and has WAY less potential to harm than ammonia. I've used them extensively as a way to check responsiveness.


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## NomadicMedic (Nov 28, 2014)

People still have ammonia around?

And a trap squeeze is easier than an NPA. If they want to be "unresponsive" but they're ventilating without issue, I just leave them alone. I've got no reason to cram a 34fr hose up someone's snout. In my book, that's punitive and inappropriate.


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## Gurby (Nov 29, 2014)

I've done it on suspected opiate OD's who aren't responding to narcan, have depressed respirations and are in and out of consciousness.  I wouldn't use it on an etOH or something, though.


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## NomadicMedic (Nov 29, 2014)

A suspected OD with depressed respirations is certainly a different situation than simply "checking responsiveness" in an "unconscious" person.

Good rule of thumb: Don't use an airway adjunct unless you need to use a tool to manage the patients airway.


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## usalsfyre (Nov 29, 2014)

DEmedic said:


> People still have ammonia around?
> 
> And a trap squeeze is easier than an NPA. If they want to be "unresponsive" but they're ventilating without issue, I just leave them alone. I've got no reason to cram a 34fr hose up someone's snout. In my book, that's punitive and inappropriate.


It's not the one's who respond to a trap squeeze or that obviously want to be "unconsciois" I use it on. It's those boderline, possibly legit medical issue patients that MAYBE narcotized ect that I'll pull the trigger on an NPA for.


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## NomadicMedic (Nov 29, 2014)

usalsfyre said:


> It's not the one's who respond to a trap squeeze or that obviously want to be "unconsciois" I use it on. It's those boderline, possibly legit medical issue patients that MAYBE narcotized ect that I'll pull the trigger on an NPA for.



But that's not what you wrote.



usalsfyre said:


> I've used them extensively as a way to check responsiveness.



An NPA isn't a tool to check for responsiveness. It's an airway adjunct. If they need assistance with ventilation or you want to assure an airway while you wait for the Narcan to kick in... Sure. But as a assessment tool? That's pretty sketchy.


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## Carlos Danger (Nov 29, 2014)

DEmedic said:


> An NPA isn't a tool to check for responsiveness. It's an airway adjunct. If they need assistance with ventilation it you want to assure an airway while you wait for the Narcan to kick in... Sure. But as a assessment tool? That's pretty sketchy.



Not as an assessment maneuver per se, but I think its perfectly legit for those "I think this dude might be faking but I'm not sure.....if he really is out of it I want an NPA, and if he's really not out of it, I'll know as soon as I try to place it" situations.


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## NomadicMedic (Nov 29, 2014)

Okay. We'll just agree to disagree on this.


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## Akulahawk (Nov 29, 2014)

I don't use airway adjuncts as an assessment tool. I'm going to use my various airway adjuncts because my assessment tells me that the patient needs some kind of airway management because the patient can't manage it effectively on their own.

If the patient is faking well enough, they'll get a surprise when they get that airway adjunct placed...


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## Twitch559 (Nov 30, 2014)

COtoWestAfricaMEDIC said:


> NPA to check for responsiveness on a possible drunk case to see if they are faking or if you do not stay awake on me.


Where I was doing ride a longs, we have a lot of drunks that "pass out*" and snore so we are required to attempt an opa. 

*they would stop responding because we would not speak Spanish to them when they knew English.


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## jwk (Dec 1, 2014)

Remi said:


> Not as an assessment maneuver per se, but I think its perfectly legit for those "I think this dude might be faking but I'm not sure.....if he really is out of it I want an NPA, and if he's really not out of it, I'll know as soon as I try to place it" situations.


If you think an NPA is a reasonable assessment tool, you need to work on your assessment skills.  Sorry.  The truth hurts.


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## Carlos Danger (Dec 1, 2014)

jwk said:


> If you think an NPA is a reasonable assessment tool, you need to work on your assessment skills.  Sorry.  The truth hurts.



Who ever said anything about it being a "reasonable assessment tool"?

There is a big difference between doing an intervention just to what the response is, and doing an intervention because you think it's likely indicated, though you can't be sure.

If you think no one in the field will ever successfully fool you feigning unresponsiveness, then you need to spend some more time in the field. As you gain experience you'll also gain humility.


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## DesertMedic66 (Dec 1, 2014)

Remi said:


> If you think no one in the field will ever successfully fool you feigning unresponsiveness, then you need to spend some more time in the field. As you gain experience you'll also gain humility.


This. Every now and then we will get patients who we think are acting however they are doing such a good job that we aren't 100% sure they are faking. Mix that in with snoring respirations and they bought themselves an NPA (after I warn them if they don't wake up a tube is going down their nose). 

I don't use it as an assessment tool at all


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## jwk (Dec 1, 2014)

Remi said:


> Who ever said anything about it being a "reasonable assessment tool"?
> 
> There is a big difference between doing an intervention just to what the response is, and doing an intervention because you think it's likely indicated, though you can't be sure.



Sorry - if it quacks like a duck...it's a duck, regardless of what you call it.  After nearly 40 years, I know what a duck looks like.  There are LOTS of ways to assess an adequate airway and the need (or not) for airway support - and ramming in an NPA because you can't tell whether they're faking it or not is a lousy assessment move.



> Not as an assessment maneuver per se, but I think its perfectly legit for those "*I think this dude might be faking but I'm not sure*.....if he really is out of it I want an NPA, and if he's really not out of it, I'll know as soon as I try to place it" situations.


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## Carlos Danger (Dec 1, 2014)

jwk said:


> Sorry - if it quacks like a duck...it's a duck, regardless of what you call it. After nearly 40 years, I know what a duck looks like.  There are LOTS of ways to assess an adequate airway and the need (or not) for airway support - and ramming in an NPA because you can't tell whether they're faking it or not is a lousy assessment move.



Good for you if you are never surprised at someone's willingness to accept an NPA. You win.

Just keep in mind that the OR and the field are very different animals.


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