# NG/OG tubes with intubation



## Veneficus (Feb 11, 2013)

n7lxi said:
			
		

> *There was a discussion from the rectal ASA thread about NG/OG tubes. I've moved some of those posts here to facilitate a discussion about NG/OG tubes.
> 
> Do you use them? Why or why not?*





jroyster06 said:


> If your pt is intubated, You should have an NG tube. Why not disolve the ASA and put it down NG tube?



an NG tube prehospital is not standard or even a majority practice in EMS.


----------



## jroyster06 (Feb 11, 2013)

Well that solves that. I suppose we are lucky and have NG tubes in our protocols. I am surprised they aren't prehospital popular. I think they are a great thing to have and I use them regularly.


----------



## NomadicMedic (Feb 11, 2013)

*rectal administration of ASA*



Veneficus said:


> an NG tube prehospital is not standard or even a majority practice in EMS.



It's not? We place an OG/NG with all tubes. I learned it as a "standard practice".


----------



## Hunter (Feb 11, 2013)

Veneficus said:


> an NG tube prehospital is not standard or even a majority practice in EMS.



Should be... You get ROSC, I mean why not, I understand if you can't stop in the middle of a code  to drop an NG tube, but after rosc dropping an ng tube takes 30 seconds.


----------



## jroyster06 (Feb 11, 2013)

Hunter, I use them in codes alot. Usually during my 45 min transport time i find time to do it, ESP if the pt has been ventalated by bystanders or BVM and has gastric distention.


----------



## mycrofft (Feb 11, 2013)

NG tubes in protocols. Hm. I can say I've seen some abdominal tympany when taking a patient over from less-trained rescuers that tempted me to use a trochar liked a bloated horse.

Any studies?


----------



## boerbull (Feb 11, 2013)

NGtube is also standard in my protocol, but I must be honest with the short transport times I have, I usually don't do it. No excuse I know especially after using BVM.


----------



## DesertMedic66 (Feb 11, 2013)

NG/OG tubes aren't in my protocols. But then again neither is ped intubation...


----------



## Veneficus (Feb 11, 2013)

Hunter said:


> Should be... You get ROSC, I mean why not, I understand if you can't stop in the middle of a code  to drop an NG tube, but after rosc dropping an ng tube takes 30 seconds.



I agree they should be. 

In fact I think it is borderline negligent not to, especially if you have been bagging prior to a tube with some kind of occlusive cuff.

But as you know, practice is not changed by my force of will.


----------



## Smash (Feb 11, 2013)

Standard practice in anyone who is intubated.  Reduce splinting from distended abdo in the previously ventilated patient and hopefully help reduce VAP from regurgitation.
EDIT:  And (possibly because I am a r'tard) they are 10 times harder to get in than the tube was in the first place.


----------



## Shishkabob (Feb 11, 2013)

Standard here.  If they have an ET / King, they have a NG/OG tube.  Did one 2 weeks ago on my last arrest.


----------



## medicsb (Feb 11, 2013)

Meh.  One place I worked carried them.  I placed one only once.  Had plenty of tubes, rarely felt the need to place one.  Usually busy with other stuff.  

Based on this thread, I am doubtful they serve any use other than to make some medics feel superior for using them when others (the majority, most likely) don't.


----------



## Shishkabob (Feb 11, 2013)

medicsb said:


> Based on this thread, I am doubtful they serve any use other than to make some medics feel superior for using them when others (the majority, most likely) don't.



You mean besides reducing gastric distension and allowing active direct gastric suctioning?  


Just because some agencies are more progressive / aggressive / up-to-times with medicine doesn't mean they're trying to make their field crews feel slightly superior... it means it's medicine, it has a job, it works, and they do it to benefit the patient.


----------



## NomadicMedic (Feb 11, 2013)

Transporting an arrest with ROSC always gets an OG/NG. BLS loves to blow those people up like balloons. I also place them in submersion incidents. Ive been unlucky to have more than my share of drownings and I can usually hoover at least a couple of Toomey syringes of Atlantic Ocean out of them. 

I don't feel as that that makes me superior. It just means I'm following my agency's standard of care in relieving gastric distention.


----------



## medicsb (Feb 11, 2013)

Linuss said:


> Just because some agencies are more progressive / aggressive / up-to-times with medicine doesn't mean they're trying to make their field crews feel slightly superior... it means it's medicine, it has a job, it works, and they do it to benefit the patient.



How is placing an NG tube progressive?  I mean, I won't say it is regressive.  But, I am doubtful that it is really necessary.  It's just something else for you to do.  It seems squarely neutral, probably does nothing in the prehospital setting unless there is obvious gastric distention that is actually hindering ventilation (which I'll bet is very very rare).


----------



## EMT B (Feb 11, 2013)

My system, you can only give activated charcoal via an ng tube...


----------



## Medic Tim (Feb 11, 2013)

EMT B said:


> My system, you can only give activated charcoal via an ng tube...


They are also required for all ped intubations in ME. I place them on everyone I tube.


----------



## mycrofft (Feb 11, 2013)

Doesn't nasogastric suctioning require a far less, _ENERGETIC_ degree of suction versus oropharyngeal?

(20-40 mmHg versus 120-150 mmHg).


----------



## jwk (Feb 11, 2013)

medicsb said:


> How is placing an NG tube progressive?  I mean, I won't say it is regressive.  But, I am doubtful that it is really necessary.  It's just something else for you to do.  It seems squarely neutral, probably does nothing in the prehospital setting unless there is obvious gastric distention that is actually hindering ventilation (which I'll bet is very very rare).



This.

IF you have lesser trained individuals bagging patients and blowing up their stomachs to the point that adequate ventilation is difficult, then they either need to A) learn how to properly bag a patient or B) do compression-only CPR and wait for a better trained individual to place a more definitive airway.  This is exactly why ACLS has moved away from early airway management - sometimes it does more harm than good.

IF the abdomen isn't distended, there really isn't a reason to drop an NGT.


----------



## jwk (Feb 11, 2013)

mycrofft said:


> Doesn't nasogastric suctioning require a far less, _ENERGETIC_ degree of suction versus oropharyngeal?
> 
> (20-40 mmHg versus 120-150 mmHg).



If you are really wanting to empty the stomach contents, crank it up all the way until stuff quits coming out, and then turn it back down in the 80-100 range.  Continuous high suction to an NGT (200-250+) can injure the stomach mucosa.  If you're not getting a return, either reposition your tube (frequently they're not in far enough), make sure it's down the right pipe, and if you still get no return, turn the suction down below 100 or off.


----------



## jroyster06 (Feb 11, 2013)

Whats the best way that yall have gotten an NG or OG around the King Airway... I havent had much luck.


----------



## Medic Tim (Feb 11, 2013)

jroyster06 said:


> Whats the best way that yall have gotten an NG or OG around the King Airway... I havent had much luck.



Never used a regular king. All the ones I have used had the og/suction port on the back so it has never been an issue.


----------



## usalsfyre (Feb 12, 2013)

medicsb said:


> Based on this thread, I am doubtful they serve any use other than to make some medics feel superior for using them when others (the majority, most likely) don't.


What exactly did this contribute besides showcasing what seems to be a growing contempt for paramedics?

To answer the OPs question, I've been placing them pretty much since I got out of school. Usually on intubated patients, but not uncommonly or SBO or upper GI bleed patients.


----------



## boerbull (Feb 12, 2013)

My service recently started using the I-Gel O2. According to the manufacturer it is very easy to insert the NG tube, that is supplied with it. Do any of you guys have any experience with it? I haven't used it yet, cause it is used as a backup for ET


----------



## Merck (Feb 12, 2013)

A gastric tube is just good practice.  As has been mentioned there is benefit in gastric insufflation in/after a cardiac arrest.  As well, gastric emptying can help to decrease the incidence of HAP/VAP or a pneumonitis.

I try to just place an OG when I DL/Glidescope for an intubation.


----------



## Dwindlin (Feb 12, 2013)

My opinions lean with jwk and medicsb.  People throwing around the reduced pneumonia can you cite that please?  Only thing I have found is related to feeding, not initial intubation.


----------



## medicsb (Feb 12, 2013)

usalsfyre said:


> What exactly did this contribute besides showcasing what seems to be a growing contempt for paramedics?



Yeah, I guess it was a little bit uncalled-for, but it was a jab at those who act astonished that something isn't "standard" outside their own system especially when they probably known better.  

Moving on...

I'm looking around and I'm not finding anything that recommends placing an NG tube post ETI outside of the presence of gastric distention.  So, the idea of placing an NGT on all intubated patients seems a little cookbook-ish to me.  

But, I've come across some tidbits that are relevant to this practice:

Am J Med. 1992 Aug;93(2):135-42.
A predictive risk index for nosocomial pneumonia in the intensive care unit.
"Endotracheal intubation, altered mental status, and NG tube are associated with the highest risk of [nosocomial pneumonia]..."

J Neurosurg. 2013 Feb;118(2):358-63. 
Pneumonia in patients with severe head injury: incidence, risk factors, and outcomes.
"3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury."

Principles of Critical Care, 3e
Chapter 43. Ventilator-Associated Pneumonia
"The nasogastric tube is not widely considered to be a potential risk factor for pneumonia, but it may increase oropharyngeal colonization, cause stagnation of oropharyngeal secretions, and increase reflux and the risk of aspiration."


----------



## Veneficus (Feb 12, 2013)

Just my thoughts, but I think the practice comes from trauma services.

If you recall, most trauma at one point was met with surgery. Prior to surgery when patients are not NPO (of which the required time has decreased over time) removing stomach contents prior to surgery was easily accomplished by og/ng.

The potential mechanism of aspiration pneumonia is well known and accepted. 

However, as recent as a study published in medscape last week, the effectiveness of NPO in decreasing aspiration pneumonia is highly suspect.

I think this would also apply to emergency patients of all types.

Having said that, and never having before been accused of being cookbook, until some powerful or multiple studies compel the a change in the NPO practice, continuing it and by extension, evaculating stomach content in the critically ill, like a post resuscitation patient should probably continue.

Aside from aspiration, in severe illness or injury, there is dysfunction of both the mucosa and the various functions of the gut. It may be possible that removing stomach content could have benefit. 

But after all of this, if you are placing an NG just to place it and do nothing with it, then I agree it is an unindicated treatment and as such, a medical error.


----------



## Dwindlin (Feb 12, 2013)

medicsb said:


> Yeah, I guess it was a little bit uncalled-for, but it was a jab at those who act astonished that something isn't "standard" outside their own system especially when they probably known better.
> 
> Moving on...
> 
> ...



This is the stuff I was finding...

On further reading it seems NG/OG is actually a risk factor for pneumonia, thus the recommendation for post-pyloric feeding in ICU patients.


----------



## Handsome Robb (Feb 12, 2013)

medicsb said:


> Meh.  One place I worked carried them.  I placed one only once.  Had plenty of tubes, rarely felt the need to place one.  Usually busy with other stuff.
> 
> Based on this thread, I am doubtful they serve any use other than to make some medics feel superior for using them when others (the majority, most likely) don't.



How does placing an NG/OG tube make us feel superior? It's a standard procedure for patients with advanced airways in place. 

They reduce gastric distention, reduce the risk of vomiting and potential aspiration, especially if you're using a supraglottic airway. ETT isn't as big of a deal but I'd really rather my intubated patient not vomit with that tube and tube holder in place. Also give you a route to administer medications. Aspirin and activated charcoal are the only two I can think of in the prehospital environment but if you have time why not place one. Just one less step for the hospital to do especially if they're intubated and you're not using the port on a King LTD to place it so it's going to end up coming out when they swap the tube anyways. 

We use King airways as a first line airway in cardiac arrest and just recently have switched to wanting them to be used or at least considered in respiratory arrest patients as well. It takes me 15 extra seconds to place it...Drop the king, confirm placement, secure it, measure the OG lube it a bit and put it through the port. There's no excuse not to. It's standard to place them with advanced airways here. 

I also try to place them in ingestion ODs that occurred a short time before my arrival. Depends a lot on the patient though. We don't carry activated charcoal in my system anymore but there's no reason I can't try to suck as much of the medication that hasn't been absorbed out of their stomach to reduce the amount that's actually absorbed into and circulated around their system. 

Random anecdote but have you ever seen a patient with a King airway in place vomit? That little OG port turns a relatively benign vomit into a geyser-like stream of emesis. Not pretty and they shoot a good distance, especially if they're vomiting violently.


----------



## Summit (Feb 12, 2013)

I agree that NG for all ETT is cookbookish. I guess I don’t know what percent non-deceased EMS patients keep their tubes for long, or go to surgery. If the patient has a distended abdomen or looks like have a long ventilated hospital course and/or a surgical course, NG seems like a good idea and/or is inevitable.

Now, on this thread and in response to medicsb:
http://www.smiths-medical.com/upload/products/mainImages/tube all.JPG
You don’t get the gastric sxn, but for long transports, or for patients who keep their tube, better outcomes by reducing leakage past the cuff or preventing extubation/reintubation with a capable device. This only works if the receiving facility is used to the idea of continuous aspiration
of sub-glottic secretions and I would assume any ED/ICU would be familiar with this idea as the evidence supporting it has been around since at least the 1990s AFAIK. We use a similar device at our hospital.


----------



## Carlos Danger (Feb 14, 2013)

Gastric tubes are being used less and less in the ICU and perioperative settings, because they are actually associated with HIGHER rates of infection.

More importantly for EMS, they don't prevent aspiration, either. In fact some studies show an increased risk of it for 2 reasons:

You aren't able to evacuate all the stomach contents, and
Tubes reduce LES and UES tone, making it easier for gastric contents to find their way back up the goose.

Anecdotally, I've seen a lot more emesis in patients having gastric tubes placed than in ones who don't. I've never been in the habit of placing gastric tubes in the field, and have never had a problem with emesis post-intubation.

Maybe if someone's gut is blown up like a balloon a gastric tube makes sense, but there's no reason to place them routinely.


----------



## medicdan (Feb 14, 2013)

old school said:


> Gastric tubes are being used less and less in the ICU and perioperative settings, because they are actually associated with HIGHER rates of infection.
> 
> More importantly for EMS, they don't prevent aspiration, either. In fact some studies show an increased risk of it for 2 reasons:



Mind citing some sources for this?


----------



## medicsb (Feb 14, 2013)

emt.dan said:


> Mind citing some sources for this?



Already done, see post 27.


----------



## Carlos Danger (Feb 14, 2013)

emt.dan said:


> Mind citing some sources for this?



A better question is, would anyone mind citing sources _in favor of_ routine OGT placement?  

It's the intervention that has to prove itself, not the other way around.

The only reference I have handy is my class notes.


----------



## mycrofft (Feb 15, 2013)

Veneficus said:


> But after all of this, if you are placing an NG just to place it and do nothing with it, then I agree it is an unindicated treatment and as such, a medical error.



Just to be uptight about this: if they did it on purpose and had no indication of it, or no intention of using it, it was a tort. Same as unnecessary backboarding or starting IV's "just in case".


----------



## NomadicMedic (Feb 15, 2013)

Again, I use an NG tube to relieve gastric distinction, which occurs 99% of the time I have BLS people bagging. Not a rip on BLS folks... It's a hard skill to master, and most just aren't very good at it. 

I also use them to remove sea water following a surf rescue/resuscitation.

I believe both of these indication warrant an NG tube.


----------



## Clare (Feb 15, 2013)

They are not used in NZ and I didn't learn how to place them.

For newborns we can decompress the stomach with a small suction catheter placed into the tummy, but I forget why and when but I do remember reading it somewhere.


----------



## jwk (Feb 16, 2013)

n7lxi said:


> Again, I use an NG tube to relieve gastric distinction, which occurs 99% of the time I have BLS people bagging. Not a rip on BLS folks... It's a hard skill to master, and most just aren't very good at it.
> 
> I also use them to remove sea water following a surf rescue/resuscitation.
> 
> I believe both of these indication warrant an NG tube.



And again - a reason for poorly trained individuals NOT to attempt ventilating the patient.


----------



## jwk (Feb 16, 2013)

old school said:


> Gastric tubes are being used less and less in the ICU and perioperative settings, because they are actually associated with HIGHER rates of infection.
> 
> More importantly for EMS, they don't prevent aspiration, either. In fact some studies show an increased risk of it for 2 reasons:
> 
> ...



Bingo, bingo, and .... bingo!


----------



## NomadicMedic (Feb 16, 2013)

jwk said:


> And again - a reason for poorly trained individuals NOT to attempt ventilating the patient.



That's a discussion that goes beyond NG tubes.


----------



## 18G (Feb 25, 2013)

I look at NG tubes as an adjunct to airway management especially in children and infants. In this population, even with proper bagging technique, its not hard to reach airway pressures that will divert air into the stomach. I think we all know what happens when the diaphragm and organs are displaced upward into the chest cavity. IMPAIRED VENTILATION.  

I agree with NG tubes in adults as well.


----------

