NPA or OPA

MrBrown said:
Risk of nasal airway use and head injury is significantly overstated, just be careful, if significant resistance is encountered then stop and try the other nostril.
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It may be overstated, but is it prudent to tell people its ok to use an NPA in someone where head trauma is under suspicion?
 
8jimi8 said:
It may be overstated, but is it prudent to tell people its ok to use an NPA in someone where head trauma is under suspicion?
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Brown is quite right, Sir! What he possibly hasn't made clear is that there is a caution attached to using NPA's with head injuries but it's certainly not a contraindication.
 
AndyK said:
Brown is quite right, Sir! What he possibly hasn't made clear is that there is a caution attached to using NPA's with head injuries but it's certainly not a contraindication.
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The spine is very hard to damage. If someone sustained injuries enough to injure their back, i would be VERY suspicious for head trauma as well.

consider throwing a lollipop down hard enough to break the stick...



In any case, what I learned was that suspected basilar skull fracture was a contraindication,

what did everyone else learn?

I for one would rather use airway maneuver like a jaw thrust/sellicks to manage an airway if i did not feel comfortable.
 
That's kind of what I was thinking, but I wasn't sure. I know that none of my patients with a head injury will get oxygen, no sir, because after 4-6 minutes with oxygen, the brain cells start to die, right?

The above was directed at Linuss btw
 
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8jimi8 said:
In any case, what I learned was that suspected basilar skull fracture was a contraindication
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It used to be, I certainly remember being told that aswell, but the tutor on my last update training stated it's now "with caution" rather than an absolute contra.
 
This is not new information. It is just still taught, because idiots put the fear in new students.

This happens to be a question I ask every trauma Dr i meet. I have never had one that agreed with this myth. Of course if you have out of date med control, then you must follow what they say. So follow your protocols.
 
Imagine if they really taught what we need to know rather than perpetuating misinformation.


I DONT KNOW WHY I WOULD EVER QUESTION HELICOPTER DOCTOR BROWN
 
8jimi8 said:
Imagine if they really taught what we need to know rather than perpetuating misinformation.
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It's not as simple as that.

What we need to know is constantly changing and evolving. Medical science isn't new but it's still growing. Relative to medical science, modern emergency medicine (with ambulances and field providers with training a bit more extensive than how to operate the stretcher) is still somewhat young.

On top of that, what one group thinks is best might not be what another group thinks is best. One state might subscribe to one group's point of view and another state subscribes to another point of view. That's why some EMT-Bs can do simple airways or check blood sugar levels while others can't.

And most of the people perpetuating misinformation aren't doing it deliberately. They're just repeating what they were taught, which was most likely true at one point in time, at least according to what one research group believed at the time.
 
fast65 said:
That's kind of what I was thinking, but I wasn't sure. I know that none of my patients with a head injury will get oxygen, no sir, because after 4-6 minutes with oxygen, the brain cells start to die, right?

The above was directed at Linuss btw
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I really hate trying to sounds intelligent so please forgive me in advance. That's kind of true with head injuries, but somebody also summed it up pretty well on another thread, which was on increased ICP, as the deadly twins: hypoxia and hypotension, and later somebody appended hypercapnia and called it the deadly triplets (how I remember it now). Too much O2 is bad, and that's probably because of free radicals (the guys hurting the brain), and stenosis in the brain since O2 is a vasoconstrictor , but giving them a little bit of O2 may be beneficial (saturate hgb w/ O2, increase BP to prevent ischemia, but don't give too much that you close the vessels and cause it). I'd guess that a NC @ 4-6 L/m would probably be the right dose.
 
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Aprz said:
I really hate trying to sounds intelligent so please forgive me in advance. That's kind of true with head injuries, but somebody also summed it up pretty well on another thread, which was on increased ICP, as the deadly twins: hypoxia and hypotension, and later somebody appended hypercapnia and called it the deadly triplets (how I remember it now). Too much O2 is bad, and that's probably because of free radicals (the guys hurting the brain), and stenosis in the brain since O2 is a vasoconstrictor , but giving them a little bit of O2 may be beneficial (saturate hgb w/ O2, increase BP to prevent ischemia, but don't give too much that you close the vessels and cause it). I'd guess that a NC @ 4-6 L/m would probably be the right dose.
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You see, here's the thing about ICP. In a patient with increased ICP you're kind of stuck in the middle; on one end you have a risk of cerebral herniation, and on the other end you have the risk of ischemia. So, as ICP increases the body begins to compensate by decreasing CPP, which then results in an increase in MAP, causing vasodilation and increased cerebral blood flow; this process increases ICP even more and exacerbates the patients condition. Now, if we give the patient oxygen then that vasoconstriction should shunt some of the blood away from the patients head, allowing for a decrease in ICP. So we would want to give high-flow oxygen, correct?

But, on the other end, if cerebral blood flow decreases, then CPP does as well, this results in the brain becomes ischemic and brain cells will soon begin to die. So, without being able to determine CPP in the field, how do we walk that fine line? Do we try to determine the lesser of the two evils?

This is just my understanding of ICP so far, I'm pretty new to the topic, so if anyone has anything to add, or anything to correct, please do so.
 
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I was taking a stab at this, I don't really know it. I don't want to give you the wrong info, it was wrong of me to have people believe a NC is appropriate for all patients (I didn't clarify this), it's based on the patient (e.g. the patient is unconscious with irregular respirations then you may want to ventilate them instead), and I don't want to deviate further from the topic on airway adjunts so....

There is an old thread on ICP http://www.emtlife.com/showthread.php?t=72
One on Cushing's Triad that's more recent http://www.emtlife.com/showthread.php?t=21998
The EMTSpot has a thing on head injuries http://theemtspot.com/2009/07/16/treatment-of-head-injury/

I think if you are monitoring EtCO2, I think you could determine if they are getting too much or too little oxygen.

or we could create a new one again. <_<

I'd like to add to an earlier question about what does our local EMT program teach. They teach that significant head trauma is a contraindication for NPAs. You guys have posted up enough statistics and information on the unlikeliness of sticking it in the brain though so maybe they'll eventually change to "with caution" like I read somebody else program does.
 
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Aprz said:
I was taking a stab at this, I don't really know it. I don't want to give you the wrong info, it was wrong of me to have people believe a NC is appropriate for all patients, it's based on the patient (e.g. the patient is unconscious with irregular respirations then you may want to ventilate them instead), and I don't want to deviate further from the topic on airway adjunts so....

There is an old thread on ICP http://www.emtlife.com/showthread.php?t=72
One on Cushing's Triad that's more recent http://www.emtlife.com/showthread.php?t=21998
The EMTSpot has a thing on head injuries http://theemtspot.com/2009/07/16/treatment-of-head-injury/

I think if you are monitoring EtCO2, I think you could determine if they are getting too much or too little oxygen.

or we could create a new one again. <_<
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Almost every thread about oxygenation and ventilation and airway turns into

Oxygen bad or good.

Whether or not oxygen is good or bad. Or an npa is used or an opa is used. It doesnt matter what is right or what you believe. Its just what your protocols say. If your protocols say no one with a skull fracture gets an npa then no one with a skull fracture gets an npa.

One of those threads were mine and I still didn't get the answer I was looking for lol. Because it turned into o2 vs no o2.
 
Haha, I know what you mean. That's why I decided to step off a little bit and turn it back to airway adjuncts. Some of us have cool protocols where it's not the end all final answer. In the county I live in, on the very first few pages somewhere, it says that "sound medical judgement supercedes protocols; these are only guidelines". I don't think it means do whatever the heck you want, but also saying use your brain and treat appropriately, not just because the protocol says so. I think that's where conversations like this turn out to be nice. By the way, that's me paraphrasing the protocol, not quoting it word to word verbatim. :s

Edit: It says

Treatment algorithms should be used as a guideline and are not inteded as a substitute for sound medical judgement. Unusual patient presentations make it impossible to develop a protocol for every possible patient situation.
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