NG Tubes

[Doczilla]

We put one in the other night when this drunk chic chewed a bottle of xanax right in front of us...but the crazy thing is hospitals in our area are steering away from gastric pumping and lavage...cause its so messy...that's crazy if you ask me...but they say it ain't killing them...they can just sleep it off...blew my mind!!!

Gastric lavage and charcoal are not the harmless interventions many have thought them to be. The old "activated charcoal binds everything" is not true, and it conveys benefit in a very few overdoses. When it does, it is not the single dose of charcoal we have been taught, but multi-dose activated charcoal that is given repeatedly. As per the American College of Medical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists, it should only be given for carbamazepine, dapsone, phenobarbital, quinine, or theophylline. If aspirated, the charcoal causes a horrible aspiration pneumonitis. The aspiration risk goes up if you are shoving a tube into a conscious patient's throat. The sorbitol can also cause potentially serious fluid and electrolyte shifts.

For single dose activated charcoal, this position statement from the same organizations provides some guidance: "Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within 1 hour of ingestion. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour of ingestion. There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated."

Gastric lavage has not really been shown to improve outcomes in poisonings either, and it comes with some serious downsides.

The same groups put out a position paper on gastric lavage as well. "Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnor- malities, and aspiration pneumonitis. Contraindications include loss of protective airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition."

Benzodiazepine overdose, like xanax, is typically pretty benign. In a medical setting where you can monitor their oxygenation and protect their airway if needed, there is no need to administer an counteragent (flumazenil. NEVER give this for a poisoning. You know what? Never give it.) or expose the patient to additional risk of complications from gastric lavage, whole bowel irrigation, or charcoal. There are specific cases when one or more of these may be useful.

'zilla

[1EMT-P]

We use NG's & OG's on a regular basis in the ICU & yes I have used them in the field in cardiac arrests, overdoses, respiratory distress & trauma patients. As a rule of thumb if you are going to tube a patient, then an NG or OG is a good idea.

[Bieber]

Great information, everyone! Especially from the Doc.

[Just Plain Ruff]

I worked for a EMS Service where no-one had been trained to drop an NG/OG tube yet they were on our trucks.

I know that we typically do not get training on this type of tube in paramedic school yet they are on our trucks.

I routinely drop NG/OG tubes in all post arrest patients, intubated patients and others depending on circumstances.

I agree with you doc that inserting an ng tube in a conscious patient can be dangerous. Consider the risks of insertion versus the risk of aspiration or gagging which can cause regurgitation resulting in aspiration.

I am a very very strong advocate of not inserting one if you have never done one even though the tubes are on your trucks.

And remember, rule of thumb, head injury gets an OJ tube not an NG tube unless you have CT scan confirmation that there is no basilar skull fracture - eg no NG insertion on head trauma patients.

[HERBIE1]

My how things have changed. The days of grabbing an Ewald tune(aka the garden hose) and the charcoal are distant memories from my days in the ER. I always said that if folks knew what was waiting for them in an ER after their OD, they would have either chosen another method as a suicide gesture, or simply given up on the idea completely. Gowns, gloves, face shields, masks, shoe and head covers- yuck, and working those monster sized syringes.... That damned charcoal got into everything, too. LOL.

As for NG insertions, I've dropped many, but never on the streets- not part of our protocol, nor do we carry them. Obviously there is a benefit- especially with prolonged lay CPR or improper BVM use, but as I've said many times, our system is also not very progressive.

BTW-

Thanks for the info, doc.

[Just Plain Ruff]

I know i'm probably beating a dead horse and most members on this forum will know what I'm saying but here goes

Just because you have a tool on your truck doesn't mean you should use it especially if you are not trained to do so.

My how things have changed. The days of grabbing an Ewald tune(aka the garden hose) and the charcoal are distant memories from my days in the ER. I always said that if folks knew what was waiting for them in an ER after their OD, they would have either chosen another method as a suicide gesture, or simply given up on the idea completely. Gowns, gloves, face shields, masks, shoe and head covers- yuck, and working those monster sized syringes.... That damned charcoal got into everything, too. LOL.

As for NG insertions, I've dropped many, but never on the streets- not part of our protocol, nor do we carry them. Obviously there is a benefit- especially with prolonged lay CPR or improper BVM use, but as I've said many times, our system is also not very progressive.

BTW-

Thanks for the info, doc.

Hey Herbie, we always called the EWALD tube aversion therapy back in the days. Unfortunately those who overdose will often do it again especially if they used the first one as an attention getter or a way to keep a boyfriend or husband or girlfriend. They saw what kind of response they got when they did overdose and it sort of enforces their belief or thoughts that if they do it again when they are faced with a break up and it worked before that they will do it again.

Aversion therapy of this type worked on some on others it didn't. The ones who it worked on usually if they did commit suicide they did it with much more lethal force the next time aka gun or slit wrists or one of a myriad other ways to kill themselves.

[HERBIE1]

I know i'm probably beating a dead horse and most members on this forum will know what I'm saying but here goes

Just because you have a tool on your truck doesn't mean you should use it especially if you are not trained to do so.

Hey Herbie, we always called the EWALD tube aversion therapy back in the days. Unfortunately those who overdose will often do it again especially if they used the first one as an attention getter or a way to keep a boyfriend or husband or girlfriend. They saw what kind of response they got when they did overdose and it sort of enforces their belief or thoughts that if they do it again when they are faced with a break up and it worked before that they will do it again.

Aversion therapy of this type worked on some on others it didn't. The ones who it worked on usually if they did commit suicide they did it with much more lethal force the next time aka gun or slit wrists or one of a myriad other ways to kill themselves.

Well, maybe I'm stupid, but how can you have a piece of equipment on your rig if you cannot use it, nor have you been trained on it?

For years, our state statutes said we must carry a roll of aluminum foil to wrap newborns after an emergency delivery. Well, as long as I have been doing this, we ALWAYS had OB kits for such purposes, yet that mandate continued for that foil anyway.

I agree, sometimes the need for drama outweighs any discomfort a person may go through. You'll always get the girls who try to "end it all" by taking 4 Motrin, but you can also have the 20 something girl who took a bunch of Tylenol, because she "knew" they wouldn't really hurt her because they were OTC meds.. She called us hours later- after she was not feeling well. Last I heard about her was that she was in critical condition in the ICU and not expected to make it because her liver had shut down.

[Just Plain Ruff]

Well, maybe I'm stupid, but how can you have a piece of equipment on your rig if you cannot use it, nor have you been trained on it?

For years, our state statutes said we must carry a roll of aluminum foil to wrap newborns after an emergency delivery. Well, as long as I have been doing this, we ALWAYS had OB kits for such purposes, yet that mandate continued for that foil anyway.

I agree, sometimes the need for drama outweighs any discomfort a person may go through. You'll always get the girls who try to "end it all" by taking 4 Motrin, but you can also have the 20 something girl who took a bunch of Tylenol, because she "knew" they wouldn't really hurt her because they were OTC meds.. She called us hours later- after she was not feeling well. Last I heard about her was that she was in critical condition in the ICU and not expected to make it because her liver had shut down.

well the question of the day is that exactly Herbie.

Consider the NG tubes. I'll bet that many hospital based services have them, I know both services (hosptial based) I worked for had them on the rigs. Eventually each staff member was trained on them but I'll bet half of the staff at one of the facilities have not put a ng tube down let alone been trained on putting one in.

So the NG tube is on the truck yet some of the staff members don't know how to put one in. That's what I'm getting at.

Or the Lifepack 12 with 12 lead capability, why have one if the crews are not allowed to do one in hte field because of protocols. Sure they can do one but their protocols won't allow them. I think this one's a old example as I don't know of any service that does not have 12 leads for their medics. yet a more recent example.

Cardiac monitor with ETCo2 monitoring in built in. Staff has not been trained to interpret the ETc02 monitoring yet it's on the truck. That's one example.

I hope that makes more sense.

[HERBIE1]

well the question of the day is that exactly Herbie.

Consider the NG tubes. I'll bet that many hospital based services have them, I know both services (hosptial based) I worked for had them on the rigs. Eventually each staff member was trained on them but I'll bet half of the staff at one of the facilities have not put a ng tube down let alone been trained on putting one in.

So the NG tube is on the truck yet some of the staff members don't know how to put one in. That's what I'm getting at.

Or the Lifepack 12 with 12 lead capability, why have one if the crews are not allowed to do one in hte field because of protocols. Sure they can do one but their protocols won't allow them. I think this one's a old example as I don't know of any service that does not have 12 leads for their medics. yet a more recent example.

Cardiac monitor with ETCo2 monitoring in built in. Staff has not been trained to interpret the ETc02 monitoring yet it's on the truck. That's one example.

I hope that makes more sense.

I was looking at this from a management perspective, Ruff. If there is a piece of equipment on a rig and my employee uses it without proper training, what if they screw up? As an employer, I am liable for the consequences since I knew this crew was never trained in 12 lead EKG interpretation, yet they used it and began treating someone with a PE for an MI.(maybe a bad example, but you get my point.) Obviously the crew is in big trouble as well. That 12 lead module on the LP should be disabled- if not removed- if your system protocols do not allow you to obtain and treat someone based on a 12 lead EKG.

Now if you are talking about a failure of training, that's a different story. If the provider is working in a system, they need to be familiar with and proficient on every procedure, medication, and tool. If you are transferring in from another system, with different protocols, that person usually needs to take a system entry test and get up to date on any new procedures or tools they will encounter. It's up to the employer to ensure it's providers are adequately trained. If the person WAS trained and for some reason still does not understand how to do something, then it's still up to the employer and the system medical director to ensure that their employees are proficient and up to date with their skills.

[Medic7714]

I agree NG tubes are a great adjunct to airway management and should be used more then what they are. I don't think a lot of providers really consider their usefulness and how they improve ventilation and increase lung compliance (ie tidal volume).

They are within the scope of ALS providers here in PA and have received specific mention in the 2011 ALS protocols. Unfortunately, I cannot get the service I work for to spend $3 for an NG tube in all sizes. Im still working on it though.