# NPA Usage.



## Alas (Sep 20, 2010)

NPA and OPA- Specifically NPA, when should it be used? Had a situation where someone was doing fine one second, and went into seizure (petite mal, no twitching) Aox0, pain purpose/ pain withdraw. Slapped o2 and put on side. Pt was breathing normal rate of 22ish, v/s slightly elevated. Boss says i should put NPA next time. Others tell me it isn't nessesary. When should NPA be used, and where to draw the line?

Thank you,
Alas


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## Aidey (Sep 20, 2010)

One of my closest friends from high school has absence seizures (petite mal is the outdated name). If you tried to put an NPA in her nose she probably would have punched you when she came out of it. 

One of the things with absence seizures is that they tend not to last very long, and I personally will only treat if they don't resolve after some time. If it doesn't resolve within a short time frame, I start to suspect it is a complex partial seizure and not an absence seizure. The absence of visible "twitching" doesn't necessarily make it an absence seizure, since they may be having motor activity that isn't visible to you. Something like their eyes jerking to one side, their mouth opening and closing, or something internal like intestinal spasms. 

I wouldn't have used an NPA or O2 on this patient, unless I was using oxygen for some other issue and not the seizure.

So, to answer your question. I only use NPAs when I need a short term airway in a patient I think might have a gag reflex. Overdoses are the main situation that comes to mind, and also status generalized seizures with respiratory impairment, and maybe some sort of facial (lower jaw) trauma, but it really depends.


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## rwik123 (Sep 20, 2010)

Aidey said:


> One of my closest friends from high school has absence seizures (petite mal is the outdated name). If you tried to put an NPA in her nose she probably would have punched you when she came out of it.
> 
> One of the things with absence seizures is that they tend not to last very long, and I personally will only treat if they don't resolve after some time. If it doesn't resolve within a short time frame, I start to suspect it is a complex partial seizure and not an absence seizure. The absence of visible "twitching" doesn't necessarily make it an absence seizure, since they may be having motor activity that isn't visible to you. Something like their eyes jerking to one side, their mouth opening and closing, or something internal like intestinal spasms.
> 
> ...



Isn't any facial trauma a contradiction for NPAs?


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## Shishkabob (Sep 20, 2010)

I used an NPA for the first time just the other day.

Walked in on a patient with snoring respirations, not responsive to any stimuli.  Head tilt chin lift done, but snoring stayed.  Lubed up an NPA and tossed it in, and snoring corrected.


Patient was a DNR, so I wasn't able to do anything more advanced.  Wasn't going to attempt an OPA because if they DID have a gag reflex and vomited, sure I could suction, but it would have been a whole lot more sucky on the airway department.


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## LondonMedic (Sep 20, 2010)

I've used two in the last two days, both as rescue measures for seizing patients with airway risk when I couldn't open their jaw.


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## Aidey (Sep 20, 2010)

rwik123 said:


> Isn't any facial trauma a contradiction for NPAs?



No, facial trauma is not an absolute contraindication.


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## LondonMedic (Sep 20, 2010)

rwik123 said:


> Isn't any facial trauma a contradiction for NPAs?


No, but it should make you consider BSF or rearranged nasal anatomy which would make you _cautious_ about an NPA.


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## abckidsmom (Sep 20, 2010)

I use an NPA whenever someone presents with an altered mental status that needs airway assistance and still has a gag reflex.

Snoring respirations, secretions, suctioning, clenched teeth, or just deeply drunk...NPA.


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## LondonMedic (Sep 20, 2010)

abckidsmom said:


> I use an NPA whenever someone presents with an altered mental status that needs airway assistance and still has a gag reflex.
> 
> Snoring respirations, secretions, suctioning, clenched teeth, or just deeply drunk...NPA.


Do you consider the risks and benefits in all these patients?


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## abckidsmom (Sep 20, 2010)

LondonMedic said:


> Do you consider the risks and benefits in all these patients?



Forgot that I was posting on the EMS forum and needed to be prepared for an inquisition.



			
				me said:
			
		

> _After considering the risks and benefits_, I use an NPA whenever someone presents with an altered mental status that needs airway assistance _after simple positioning maneuvers have failed to provide a patent airway_ and still has a gag reflex.
> 
> Snoring respirations, secretions, suctioning, clenched teeth, or just deeply drunk...NPA.



When you are taking care of a patient with an altered mental status, would you NOT manage their airway?  I'm not very clear what you're talking about here.


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## LondonMedic (Sep 20, 2010)

abckidsmom said:


> When you are taking care of a patient with an altered mental status, would you NOT manage their airway?  I'm not very clear what you're talking about here.


Managing an airway does not necessarily mean sticking a piece of plastic in it.


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## abckidsmom (Sep 20, 2010)

LondonMedic said:


> Managing an airway does not necessarily mean sticking a piece of plastic in it.



Can you spell it out for me then?


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## Amycus (Sep 20, 2010)

abckidsmom said:


> Can you spell it out for me then?




My thought would be- If the PT is altered but they are talking, ot mumbling such, or any obvious signs of a patent airway, they don't need an NPA. If the PT is altered and breathing in in a very slow, almost absent manner (i.e. 4 breaths a minute), I'm likely going to throw an NPA in there and start bagging. If the PT comes around (narcan, D50, etc), and they don't need the assistance, it can be just as easily removed.

Generally speaking, while I am kinda new at this whole EMT thing, if I'm bagging a PT, I'm likely going to throw an adjuct in there- unless the PT is totally AOx3/4...in which case, bagging them won't be the easiest thing in the world anyways (although still doable). 

I dunno, that's my two cents in the matter. If the PT can't protect their airway due to severe AMS and requires bagging, I'll use one. Otherwise, I'll just slap a NRB on and monitor their respirations.

edit- and yes, you more or less covered my thoughts I think in so few words in your post.


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## LonghornMedic (Sep 20, 2010)

Amycus said:


> Generally speaking, while I am kinda new at this whole EMT thing, if I'm bagging a PT, I'm likely going to throw an adjuct in there- unless the PT is totally AOx3/4...in which case, bagging them won't be the easiest thing in the world anyways (although still doable).



Good practice to get in the habit of. If you're bagging someone, there should be no reason why an adjunct shouldn't be used.


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## LondonMedic (Sep 21, 2010)

abckidsmom said:


> Can you spell it out for me then?


Lots of patients who are altered can actually manage their airway fine, and while we should always suspect the possibility of airway compromise, things can often be made worse by being too aggressive.

To give you two examples, when I work nights on the wards I often hear patients with signs of incomplete airway obstruction, often waking them up and asking them to sleep on their sides fixes things. Recently I saw an unconscious patient with significant blood coming out of their mouth but no actual obstruction. I elected to leave them on their side with an OPA and suction in place until the sitaution was more amenable, rather than immediately dump them on their back and fill their oropharynx and larynx with blood whilst I buggered about with a laryngoscope.


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## Code 3 (Sep 21, 2010)

rwik123 said:


> Isn't any facial trauma a contradiction for NPAs?



You should not use the NPA for pts with a suspected basilar skull fracture or fracture to the mid-face.


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## Shishkabob (Sep 21, 2010)

LondonMedic said:


> Lots of patients who are altered can actually manage their airway fine, and while we should always suspect the possibility of airway compromise, things can often be made worse by being too aggressive.



You realize they said "needs airway assistance" after "simple positioning maneuvers have failed", which means you kinda do need "plastic" (rubber, silicone, etc) to maintain the airway, correct?


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## abckidsmom (Sep 21, 2010)

Linuss said:


> You realize they said "needs airway assistance" after "simple positioning maneuvers have failed", which means you kinda do need "plastic" (rubber, silicone, etc) to maintain the airway, correct?



In his defense, I revised that into my statement, but it still felt pretty slammish when the examples of how not to insert plastic in the airway included an instance of inserting plastic in the airway.

But thanks for noticing.


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## MrBrown (Sep 21, 2010)

Nasal airways are largely underutilised and risks associated with head injuries are significantly overstated.

If somebody with significant maxillofacial trauma is encountered which makes it very difficult or impossible to insert an oral airway then don't use one, that is common sense.

If putting one in and you encounter significant resistance, stop and don't force it.

Never used one and only seen one used once.  

Oh and to think as recent as 2003 NPAs were an Intensive Care Paramedic skill here.  How times have changed

*Brown looks at his Lifepak 10 and sighs ....


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## abckidsmom (Sep 21, 2010)

MrBrown said:


> Nasal airways are largely underutilised and risks associated with head injuries are significantly overstated.
> 
> If somebody with significant maxillofacial trauma is encountered which makes it very difficult or impossible to insert an oral airway then don't use one, that is common sense.
> 
> ...



You poor dear...I miss that lovely red case, also...but it was extremely freeing *last week* when I threw out the last of the defib gel.  (COME ON, People!  We haven't even HAD any paddles for 8 years...why are we still carrying gel every time we pick up the bag?)

Any way, NPAs are a great tool to be had, and usually tolerated pretty well.  You've seriously never used one?  Interesting.  They've allowed me to let go of plenty a modified jaw thrust that would have caused a major cramp in the hands by the time we got to the hospital.  And cheap, too.  Easily removed, and I've never seen anything more than a little bloody mucus caused by them.


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## MasterIntubator (Sep 22, 2010)

I love my paddles..... used them last month once.  Felt good.  Just like the 80's again. Ahhhhhhhhhhh.

The NPA is one of the most useful diagnostic aids I carry in the medic unit.  I am not much into painful stimulus stuff any more... sternal rubs, fingernail crushes ( except for neurological deficit testing ).  Occasionall maybe a pinch of the skin just below the anterior portion of the shoulder... very sensitive.
If they are unconscious.... NPA.  Not many folks can take that without a flinch.  If they are seizing.... NPA.  Easy and quick.   IF the ventilations from the BVM are just not getting it done... NPA.  It helps.  

( just my take on it ).   My guedels and Bermans have dust on them. sigh..


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## Sam Adams (Sep 23, 2010)

abckidsmom said:


> I've never seen anything more than a little bloody mucus caused by them.



I on the other hand have seen massive amounts of bleeding ... It hasn't prevented me from using them, just more cautious.


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## TransportJockey (Sep 23, 2010)

I've used NPAs several times for unresponsive unknowns. Never had a problem with them. But after having to put one in myself during medic school I'm always a little more careful about inserting them than before.


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## Alas (Sep 25, 2010)

Hm, after having read all that, would everyone agree that-

Anytime Pt has trouble support own airway, use npa.
If Pt is in vegetative state, seized, aloc, but breathing normal rate good volume, no use.


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## LucidResq (Sep 25, 2010)

Unfortunately, simplifying things down to black & white, yes or no, dichotomies is often not appropriate in EMS. 

I think that in itself is a big learning curve for almost everyone. At some point you just realize that operating in shades of gray and using critical thinking skills are more important than following a formula. 

As far as NPAs go, most of the time they will not cause harm and may be worth a shot if you're questioning using them or not. My opinion is, if you're wondering whether or not an NPA will benefit a patient, go ahead and give it a shot. I had a snoring, semi conscious OD pt take a swing at me when I tried to insert one once in the ED. I stopped. It didn't cause her any harm. The thing that might stop you from doing so is when you're wondering whether or not an NPA will cause harm, as in a patient with severe facial injuries. That's a reason to be conservative right there.


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## LondonMedic (Sep 25, 2010)

LucidResq said:


> Unfortunately, simplifying things down to black & white, yes or no, dichotomies is often not appropriate in EMS.


I agree but it's something that EMS keeps trying to do.


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## jms81 (Sep 26, 2010)

I believe textbook use would say that anyone having difficulty maintaining their own airway needs manual management and/or an adjunct; and that an OPA should be used unless the Pt has a gag reflex, in which case the NPA would be used. Facial trauma is a textbook contraindication as well.

But then again, how many patients are textbook?


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## helicub81 (Oct 13, 2010)

At my school, the teachers said to just drop an OPA.  If they have a gag reflex, go to an NPA but if they don't its all good.  I guess it makes sense, because if they do have a gag reflex, the worst is a little gagging.  (not quite sure if all patients go and puke.....)  you just pull it out and shove in an NPA


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## LondonMedic (Oct 13, 2010)

helicub81 said:


> the worst is a little gagging.  (not quite sure if all patients go and puke.....)


:unsure:


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## CAO (Oct 13, 2010)

helicub81 said:


> At my school, the teachers said to just drop an OPA.  If they have a gag reflex, go to an NPA but if they don't its all good.  I guess it makes sense, because if they do have a gag reflex, the worst is a little gagging.  (not quite sure if all patients go and puke.....)  you just pull it out and shove in an NPA



Why take the risk when you could have just used the NPA to begin with?  If they do vomit, then you've got to add aspiration to the list of airway worries.


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## helicub81 (Oct 13, 2010)

Well I'd consider it because the OPA is a way better airway.


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## LucidResq (Oct 13, 2010)

The better airway is the one that works without unnecessary risk of harm to your patient.


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## CAO (Oct 13, 2010)

LucidResq said:


> The better airway is the one that works without unnecessary risk of harm to your patient.



This.

If they're going to choke on their own vomit, then the OPA isn't the better airway.

If you're going to be poking their brain with the NPA, then it isn't the better airway.

...Well, in the latter case, they're pretty much in trouble anyway.


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## usalsfyre (Oct 13, 2010)

helicub81 said:


> Well I'd consider it because the OPA is a way better airway.



All pharyngeal airways do pretty much the same thing, they use a rigid or semi rigid item to splint the upper airway open. They do nothing to reduce aspiration risk or gastric distension. If I had to choose one exclusively, I'd go with the NPA as it works for a much wider patient population than the OPA. If they can accept an OPA, they can accept a King LTS-D, which basics all over the country have been trained to safely use. This is one of the few times I think basics should be allowed to perform an invasive procedure. 

As long as we're talking about airways and the 80s in the same thread, who remembers the EOA? Bonus points for who can remember what the acronym stood for.


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## CAO (Oct 13, 2010)

Esophageal Obturator Airways?

Read about them, but I'm new enough I've never seen one used.


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## usalsfyre (Oct 13, 2010)

CAO FTW!

Actually, I'm new enough I SHOULDN'T have seen one. Unfortunately I believe it was 2003 before they were no longer required equipment to be a BLS transport unit in Virginia, which was well past their sell by date...


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## abckidsmom (Oct 13, 2010)

usalsfyre said:


> CAO FTW!
> 
> Actually, I'm new enough I SHOULDN'T have seen one. Unfortunately I believe it was 2003 before they were no longer required equipment to be a BLS transport unit in Virginia, which was well past their sell by date...



They were replaced by combitubes by the mid-90s.  Virginia just required some blind airway device, the regs didn't hold you to a certain one.

I saw one used once, on a cardiac arrest that the crew worked for just over an hour, with a 23 minute response time.  After my preceptor called the code, they pulled the lines and pointed out the lividity.  Sigh.  The good ole days, when we "made a difference" every day.


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## CAO (Oct 13, 2010)

usalsfyre said:


> CAO FTW!



Haha, nah.  FTL.

Still don't have an EMS job despite being in Medic school.  _All_ I get to do is read and practice on dummies unless I'm on clinicals <_<

Thankfully I have most of next week to do my rounds around here again to see if anyone is hiring.


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## 18G (Oct 13, 2010)

Unless a seizure patient is status you usually do not need to use an airway adjunct. Just manually maintain the airway and suction any secretions as needed. Most seizure patients come to in no time and become postictal with no airway issues. If its a tonic-clonic seizure you prob won't be able to get an OPA in due to trismus (jaw clenched) so an NPA would be your better airway if you opt to use one. 

Some seizure patients seize several times a day and they do fine without any OPA or NPA.


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## Akulahawk (Oct 13, 2010)

18G said:


> Unless a seizure patient is status you usually do not need to use an airway adjunct. Just manually maintain the airway and suction any secretions as needed. Most seizure patients come to in no time and become postictal with no airway issues. If its a tonic-clonic seizure you prob won't be able to get an OPA in due to trismus (jaw clenched) so an NPA would be your better airway if you opt to use one.
> 
> Some seizure patients seize several times a day and they do fine without any OPA or NPA.


How about using an oral screw? Anyone remember using one? At one time I was trained to use one but... that was nearly 20 years ago.

I used to work for an aquatic rehab facility. We had clients who were prone to seizure, and would do it several times in an hour. Yes, that's on anti-seizure meds. They'd seize, and pop right back out of it. We're talking short seizure, and almost NO postictal period that I could determine. And no, they didn't require any airway adjuncts. None.

IMHO, if you have to use a BVM on a seizing patient, put in an NPA while they're actively seizing as an OPA won't likely work. You'd need an oral screw to open the jaw, and chances are you'll damage teeth in the process, and then you'd be able to place the OPA.


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## CAOX3 (Oct 13, 2010)

EGTA.

Now those were the good times, intubation and lavage in one handy, dandy useless tool.


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## spike91 (Oct 14, 2010)

rwik123 said:


> Isn't any facial trauma a contradiction for NPAs?



Nope. Basal skull fracture. A lot of providers operate on the safe side and avoid NPAs on anyone with facial/head trauma in general, though.


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## Lifeguards For Life (Oct 14, 2010)

spike91 said:


> Nope. Basal skull fracture.



How would you know if they have a basilar skull fracture?


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## skivail (Oct 14, 2010)

Battle sign or Racoon Eyes but they are both later signs.


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## 18G (Oct 14, 2010)

Battle sign (retroauricular ecchymosis) and Racoon Eyes (periorbital ecchymosis) are very late signs and will usually not be present during the pre-hospital phase of care so I would not rely on those signs too much.


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## spike91 (Oct 14, 2010)

halo test. also any nasal/oral leakage.


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## JPINFV (Oct 14, 2010)

^
How many ambulances carry filter paper?


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## spike91 (Oct 14, 2010)

You can improvise.


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## LondonMedic (Oct 14, 2010)

Lifeguards For Life said:


> How would you know if they have a basilar skull fracture?


Clinical suspicion.




spike91 said:


> You can improvise.


If you think that a patient might have a BSF and has fluid leaking out of their nose and ears, you could bugger around and find something that looks like filter paper and try to elicit a poorly understood and often unclear clinical sign and end up exactly where you started - with a suspected BSF. Or you could take them to someone who _can_ make the diagnosis.


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## LondonMedic (Oct 14, 2010)

helicub81 said:


> Well I'd consider it because the OPA is a way better airway.


Of course you should consider it, but that's not what you meant, is it?


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## Lifeguards For Life (Oct 14, 2010)

spike91 said:


> halo test. also any nasal/oral leakage.



the presence of a positive halo sign is not exclusive to CSF and can lead to false-positive results.

I was only asking because you told that other bloke "no" on the facial trauma..


LondonMedic said:


> Clinical suspicion.



So basically extensive facial trauma

Hey Doc. leave some q's and a's for the rooks


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## Veneficus (Oct 14, 2010)

What really sucked about the EOA was when it came apart when you were doing CPR.

Another useless EMS device.


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## reaper (Oct 14, 2010)

spike91 said:


> halo test. also any nasal/oral leakage.



Yes, Don't believe every thing you read in the EMT books!


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## 18G (Oct 14, 2010)

You can also test the suspected CSF with a glucometer.... if mg/dl are half of the patients BG level its considered positive. Again, a time consuming task that likely won't alter your treatment but thought I would throw that out there. 

(not sure what the specificity of this test is)


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## Lifeguards For Life (Oct 14, 2010)

18G said:


> You can also test the suspected CSF with a glucometer.... if mg/dl are half of the patients BG level its considered positive. Again, a time consuming task that likely won't alter your treatment but thought I would throw that out there.
> 
> (not sure what the specificity of this test is)



I think it is relatively low. We were taught this method by one instructor who later told us not to do it.

CSF should be about 60-80% the concentration of the glucose in the blood. If you had some snot mixed with blood, it could look like CSF, and this mixture could easily test in that 60-80 percent range.

 the halo test can be viewed as 'conformation' of what you already know, at best. However if the halo test/glucose test is negative but other sign/symptoms are present, I would not rule out CSF leakage
We had a good thread on testing for CSF with a glucometer here back in (December?).


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## bigalow (Dec 7, 2010)

Personally I would not have used an NPA. O2 wasn't necessary but wont hurt if only on for a short time.

Only time I've used an NPA on a seizure patient she was full tonic/clonic x 3 minutes and wasn't adequately breathing on her own. Had to bad her. Good job on your part.


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## Bullets (Dec 7, 2010)

I love the NPA, its indicated in more of my patients then the OPA, most have a gag reflex and my first rule is don't puke on me. Its also the only airway adjunct we have, and I love asking for lube on calls, I get funny looks


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## Sam Adams (Dec 7, 2010)

bigalow said:


> Only time I've used an NPA on a seizure patient she was full tonic/clonic x 3 minutes and wasn't adequately breathing on her own. Had to bad her. Good job on your part.



I'm assuming you're meaning "bag". A small pet peeve of mine. Grocers "bag"...


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## TransportJockey (Dec 7, 2010)

Sam Adams said:


> I'm assuming you're meaning "bag". A small pet peeve of mine. Grocers "bag"...



Do you also get annoyed when someone say 'tube' instead of intubate or 'stick' instead of IV Cannulation?


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## Sam Adams (Dec 7, 2010)

jtpaintball70 said:


> Do you also get annoyed when someone say 'tube' instead of intubate or 'stick' instead of IV Cannulation?



I said small pet peeve. But it depends on whether or not I've had my coffee


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## TransportJockey (Dec 7, 2010)

Sam Adams said:


> I said small pet peeve. But it depends on whether or not I've had my coffee



Sounds about right  Coffee fixes many many things!


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## Bullets (Dec 8, 2010)

Sam Adams said:


> I'm assuming you're meaning "bag". A small pet peeve of mine. Grocers "bag"...



what do you call it? you guys dont use Ambubags?


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## Jay (Dec 10, 2010)

My $0.02... If it's a trauma Pt and you suspect possible facial injuries than absolutely do not use a NPA but an OPA is fine in this case. For a seizure, if your company wants you to use a NPA and given the circumstances, it wouldn't hurt the Pt any. In general, if the Pt is presenting well even with a low GCS but otherwise breathing normally than use common sense, why do an intervention where it is not medically necessary, which brings us to our golden rule:

_*Treat your patient, not your patients numbers*_

Cheers!


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## Fox800 (Dec 12, 2010)

Last time I went through AMLS I noticed they were really advocating NPA's for active seizures.

I love me some NPAs. Good stuff, especially with all of the ETOH/OD stuff I deal with.


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## DFW333 (Dec 16, 2010)

Ok forgive me for asking probably the dumbest question ever...but why use NPA's at all? I mean, who really needs help holding their nostrils open? That's all it does. And people who do need such help usually need it due to trauma that contraindicates the NPA. Maybe Im just over thinking it here?


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## abckidsmom (Dec 16, 2010)

DFW333 said:


> Ok forgive me for asking probably the dumbest question ever...but why use NPA's at all? I mean, who really needs help holding their nostrils open? That's all it does. And people who do need such help usually need it due to trauma that contraindicates the NPA. Maybe Im just over thinking it here?



Not the top, but the bottom end.  NPAs keep the soft palate off the retropharynx.  And I put it in anyone with a gag reflex who needs a little assistance with their airway...most commonly unconscious diabetics, while I wait for them to wake up.  I know they're approaching the land of the living when they remove the NPA.


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## mc400 (Dec 16, 2010)

used one on a code post succesful defib the other day. PT would not take an OPA and was breathing on his own so we supported his respirations and had an OPA placed.


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