# OPA/NPA trauma question



## Lisa DiMambro (Jan 15, 2016)

In a unconscious trauma patient, with oral and tongue lacerations, can a OPA be used in case of tongue swelling? I seem to recall seeing something contraindicated, but can't find it now.

Lisa


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## STXmedic (Jan 15, 2016)

The only contraindication for an OPA that I'm aware of is an intact gag reflex. You may be thinking of facial trauma with an NPA, but that's more for a suspected basilar skull fracture (and a very relative contraindication at that- cranial penetration has only ever been documented with an NG tube, not an NPA).


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## Carlos Danger (Jan 15, 2016)

Lisa DiMambro said:


> In a unconscious trauma patient, with oral and tongue lacerations, can a OPA be used in case of tongue swelling? I seem to recall seeing something contraindicated, but can't find it now.
> 
> Lisa



Sure, it would be nice to avoid placing an OPA when there is oral trauma or tongue swelling. But if they need an airway adjunct, they need an airway adjunct and that is a much higher priority than avoiding the possibility of worsening some mouth trauma. 

All of the "rules" that we learn about the use of airway adjuncts (and most everything else, too) are relative and flexible. Things like never use a NPA if you suspect a head injury, LMA's should not be used to deliver positive pressure, always assist ventilations when respiratory rate is less than 10, always intubate when the GCS is less than 8, etc are probably decent guidelines to keep in mind when you are new, because they help form the general framework for how you approach airway management and what things you should be concerned with. But remember that maintaining a patent airway is always our first priority (with the exception of a cardiac arrest, where early CPR and defib are always the first things you do), so pretty much anything it takes to do that is acceptable.


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## Brandon O (Jan 15, 2016)

Remi said:


> LMA's should not be used to deliver positive pressure



Say what now?


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> Say what now?



It's one of those "rules" that lots of people are taught that just begs to be broken. I break it pretty much everyday, in fact.


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## Brandon O (Jan 15, 2016)

Remi said:


> It's one of those "rules" that lots of people are taught that just begs to be broken. I break it pretty much everyday, in fact.



What do they think LMAs are for? Spontaneous breathing?


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> What do they think LMAs are for? Spontaneous breathing?



Well its funny, when I first learned about LMA's as a paramedic, I remember being told that they are OK as a rescue airway, but only because they are better than a cric - very insecure compared to an ETT and just not good to ventilate through, so you only use them if you basically have no other option.  And from what I hear, it sounds like that's still pretty much the prevailing attitude towards them in EMS. 

And in the anesthesia world it's actually not that different - they are generally used in cases where you plan to have the patient breath spontaneously, and people are willing to bend that rule to varying degrees based on their personal experience with them. I've never even heard of a problem being caused by ventilating through an LMA, though. I've even used them in seated and lateral cases and never really had a problem.


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## Brandon O (Jan 15, 2016)

Remi said:


> And in the anesthesia world it's actually not that different - they are generally used in cases where you plan to have the patient breath spontaneously, and people are willing to bend that rule to varying degrees based on their personal experience with them. I've never even heard of a problem being caused by ventilating through an LMA, though. I've even used them in seated and lateral cases and never really had a problem.



Correct me if I'm wrong, but by "spontaneously" you mean "on a spontaneous mode" meaning "still receiving positive pressure ventilations." You don't stick in an LMA and leave them sucking air through a T-piece or something during the case.


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> Correct me if I'm wrong, but by "spontaneously" you mean "on a spontaneous mode" meaning "still receiving positive pressure ventilations." You don't stick in an LMA and leave them sucking air through a T-piece or something during the case.



Yeah, I mean they are connected to the anesthesia circuit so they are breathing whatever gas mixture you are using and you can support them as necessary, but it's actually pretty common to place an LMA and have them breathing completely on their own. It is also common to have to provide some support, whether actually hand ventilating or just using some PS, at least for the beginning of the case while you are waiting for the induction agent to wear off, but the "goal" is to just have them breath completely on their own, as much as possible. 

One of reasons folks will choose not to use an LMA is solely because they don't think the patient will be able to breathe adequately for whatever reason, because it's a case where you plan to use a lot of narcotic, or whatever. A pretty well accepted contraindication to an LMA is a case where you know you'll need to provide PPV because they'll be paralyzed, AND you expect high inspiratory pressures. A classic example is a laparoscopic belly case (chole, hernia repair, etc) where their abdomen is insufflated so it requires higher pressures to ventilate.


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## Brandon O (Jan 15, 2016)

Sounds challenging to keep them deep enough for surgery while still retaining a reasonable respiratory drive?


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> Sounds challenging to keep them deep enough for surgery while still retaining a reasonable respiratory drive?



It can be. Healthy, non obese patients usually do fine as long as they aren't too narcotized. You just have to learn how to time things and how much of each agent to use.


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## Brandon O (Jan 15, 2016)

This would be for IV anesthesia? Or can you run gas through an LMA?


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## Carlos Danger (Jan 15, 2016)

They breathe gas through the LMA. It attaches to the anesthesia circuit the same way an ETT does. I also give gas just through the mask sometimes.


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## Tigger (Jan 15, 2016)

The patient spontaneously breathing through the LMA was on of the bigger "surprises" of my OR rotations so far. The doc let me mask ventilate them for practice after induction, but most patients really did not even need that, just a bit of support from the vent and then it was just the gas. I had no idea .


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## Brandon O (Jan 15, 2016)

Is volatile anesthesia less suppressing to the respiratory drive than IV sedation? I have a hard time imagining taking someone deep enough to cut them open while maintaining spontaneous breathing using something like propofol.


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> Is volatile anesthesia less suppressing to the respiratory drive than IV sedation? I have a hard time imagining taking someone deep enough to cut them open while maintaining spontaneous breathing using something like propofol.



By itself, gas is definitely less depressing than an equipotent dose of propofol or especially propofol + opioid. So in a case that doesn't require opioids (if you have a nerve block, or a surgeon that is very good with local) and a healthy patient, it is usually pretty easy to keep them breathing. Even with opioids you can usually get them to breathe without too much trouble as long as you time things right. It gets harder when they are heavy or in a position other than supine, or you have to use a lot of opioid for whatever reason (a very painful procedure like an ACL repair and you aren't using any regional anesthesia = lots of dilaudid, for instance).


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## Carlos Danger (Jan 15, 2016)

I generally don't give any opioid on induction; I prefer to wait until right before incision. Because that way they start breathing faster. I'm generous with the propofol and I'll use esmolol if I'm worried about tachycardia.


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## Brandon O (Jan 15, 2016)

This is a naive question, but I never entirely understood the role of opioids (fentanyl, dilaudid, etc) in general anesthesia. (I'm in a surgical ICU now and dealing with it daily.) Is the idea that to bring make them totally insensate would require far deeper anesthesia than if you combined sedation with analgesia? In other words, opioids (or epidurals, regional blocks, local, whatever) are sedation-sparing?


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## Chewy20 (Jan 15, 2016)

Brandon O said:


> This is a naive question, but I never entirely understood the role of opioids (fentanyl, dilaudid, etc) in general anesthesia. (I'm in a surgical ICU now and dealing with it daily.) Is the idea that to bring make them totally insensate would require far deeper anesthesia than if you combined sedation with analgesia? In other words, opioids (or epidurals, regional blocks, local, whatever) are sedation-sparing?




I would think they play a major role due to their predictability and work well with the cardiovascular system.


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## NomadicMedic (Jan 15, 2016)

Can I just add that discussions like this are why I still enjoy reading this forum? Kthxbi


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## Tigger (Jan 15, 2016)

Yes. Talking about this sort of stuff is fascinating. They nearly dragged me from the OR. So many questions.


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## Carlos Danger (Jan 15, 2016)

Brandon O said:


> This is a naive question, but I never entirely understood the role of opioids (fentanyl, dilaudid, etc) in general anesthesia. (I'm in a surgical ICU now and dealing with it daily.) Is the idea that to bring make them totally insensate would require far deeper anesthesia than if you combined sedation with analgesia? In other words, opioids (or epidurals, regional blocks, local, whatever) are sedation-sparing?



Good question, Brandon.

As you know, pain is more than just a _feeling_ of discomfort. It is a complex phenomenon that has many physical and psychological effects. The _feeling _of pain is just the tip of the iceberg - just a symptom of the underlying processes. Think of pain as a physical stimulus that affects the physiology like any other potent physical stimulus, like an infection or exposure to an environmental extreme. It directly affects all the major hormonal pathways - most notably the sympathetic and the RAAS and the hematologic, and in turn everything that they affect. And as you can imagine, the stimulus of surgery can be really profound, depending on the specific case. The bigger the surgery and the more tissue damage that results, the more nociceptors are activated and the more problems result.

So, any general anesthetic (volatile anesthetic gas, propofol, large doses of a benzo or a barb) will essentially turn off the higher CNS and abolish the _awareness_ of pain, but it won't do much to prevent the other physiologic effects of the painful stimulus, at least not unless you use such high doses that you start to cause other sorts of problems. That's where opioids come in. Opioids block the painful stimulus from being transmitted to the spinal cord where that stimulus would travel to second-order neurons and alert the rest of the body that it needs to react. Fentanyl is like a linebacker that stuffs the running back before he can make a down.

Also, poorly managed acute pain - even pain that the patient isn't aware of because they are asleep - can set a patient up for a tougher post op experience, even precipitating chronic pain in susceptible individuals. A couple small doses of fentanyl given at the right time during the case can avoid several mg's of dilaudid post op and potentially even refills of percocet. This is called sensitization and "wind up" (technically different things, but conceptually very similar), and it has to do with changes in the afferent neurons that are related to the effects of neurotransmitter over-exposure and possibly partly due to tolerance that develops to endogenous opioids. Chronic pain gets really complex.

Opioids are also used for purely practical reasons that have nothing to do with pain per se, like controlling tachycardia and blunting sympathetic discharge in fragile patients and keeping your patient with restless leg syndrome's feet still during a podiatric procedure (happened to me just yesterday), and smoothing out wake ups, especially in young patients and folks who seem psychologically predisposed to waking up disoriented and combative.

Opioids have downsides too, of course, which is why we generally try to limit them and use as little as we can get away with. In many cases regional anesthesia can be used to completely block the pain response while avoiding all the negative effects of opioids. In the SICU, I suspect you'll notice a big difference, for instance, in the early post-op course of a patient who had a big bowel resection or a thoracotomy with an epidural vs. someone who had the same procedure done with a bunch of narcotic.

Esmolol has some really interesting properties related to all this stuff, too. I use it a fair amount in lieu of fentanyl, more and more as I gain experience and confidence in my technique, actually. It does more than just lower the heart rate, it seems to actually block much of the negative effects of a painful stimulus in a manner similar to the opioids. There's a fair amount of research that supports it, though the mechanism is still unclear.


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## Brandon O (Jan 16, 2016)

Brilliant! Fascinating stuff.


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## jwk (Jan 18, 2016)

Remi said:


> It can be. Healthy, non obese patients usually do fine as long as they aren't too narcotized. You just have to learn how to time things and how much of each agent to use.


Ah, the ART of anesthesia.  Procedures are the easy part.


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## jwk (Jan 18, 2016)

Remi said:


> Good question, Brandon.
> 
> As you know, pain is more than just a _feeling_ of discomfort. It is a complex phenomenon that has many physical and psychological effects. The _feeling _of pain is just the tip of the iceberg - just a symptom of the underlying processes. Think of pain as a physical stimulus that affects the physiology like any other potent physical stimulus, like an infection or exposure to an environmental extreme. It directly affects all the major hormonal pathways - most notably the sympathetic and the RAAS and the hematologic, and in turn everything that they affect. And as you can imagine, the stimulus of surgery can be really profound, depending on the specific case. The bigger the surgery and the more tissue damage that results, the more nociceptors are activated and the more problems result.
> 
> ...


I'm sure you're doing as much multi-modal stuff as we are.  Funny - in the 80's when I started out, we called it "balanced anesthesia".  Now it's "multi-modal", just a different word for using a little of this and a little of that and not a lot of anything.  We do a lot of fairly big cases with zero narcotics, especially if we're able to do a block or other type of regional anesthetic.  We're doing total knees/hips with spinals as outpatient procedures - they go home about 6-8 hours post-op.  They get many different drugs along the way - lyrica, celebrex, ketamine, dexamethasone, IV tylenol, and toradol, but hopefully no narcotics.  They do surprisingly well.


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## Carlos Danger (Jan 19, 2016)

jwk said:


> I'm sure you're doing as much multi-modal stuff as we are.  Funny - in the 80's when I started out, we called it "balanced anesthesia".  Now it's "multi-modal", just a different word for using a little of this and a little of that and not a lot of anything.  We do a lot of fairly big cases with zero narcotics, especially if we're able to do a block or other type of regional anesthetic.  We're doing total knees/hips with spinals as outpatient procedures - they go home about 6-8 hours post-op.  They get many different drugs along the way - lyrica, celebrex, ketamine, dexamethasone, IV tylenol, and toradol, but hopefully no narcotics.  They do surprisingly well.



That's cool. I assume these patients are "awake" for the total joints?


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## SpecialK (Jan 20, 2016)

I don't see a problem using an LMA (or for that matter, an OPA or NPA) in the situation described.  Lacerations to the tongue or mouth shouldn't bleed that much but in the circumstance bleeding is significant I'd turn the patient on their side, suction their mouth and use an NPA if they needed an airway adjunct.  

Laryngeal masks are cheap, easy to insert, have little risk, allow for "hands-free" ventilation and can be used by all levels of ambulance personnel.  I've personally only had good results with them


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## meatanchor (Jan 22, 2016)

Question:  It appears that the NPA has become the BLS airway adjunct of choice for military and TCCC programs.  Is this because it can be theoretically be tolerated by patients with an intact gag reflex?  Also, I notice that most of individual first aid kits I've seen LEOs and military folks carry do not include a lube packet.  Are people taught to insert these dry?


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## Jim37F (Jan 22, 2016)

Yeah as far as the military is considered, facial and head trauma is not considered a contraindication for NPA, we were taught to use the patient's saliva to lube it up if you don't have a petroleum jelly pack.


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## jwk (Jan 23, 2016)

Remi said:


> That's cool. I assume these patients are "awake" for the total joints?


A little background propofol infusion so they don't hear the drills and saws.


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## SpecialK (Jan 23, 2016)

Many procedures once only performed using traditional general anaesthesia are now done with a combination of any, or all, of regional blockade, local anaesthetic infiltration (lignocaine or similar) and a little bit of sedation (midazolam or similar).

Probably the best example is cesarian section, but I've seen intramedullary nails for fractured femurs, arthroscopies, appendectomies, nerve decompressions, wrist and hand ORIFs and others all done with the patient awake.


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