OPA and NPA use

[Ace844]

Hello,

I agree with the good points reguarding NPA (suctioning, tolerance, ect....) However, OPA are better in

certain situations.

1. Basal Skull #

2. Pt. on anticoagulants, and anti-platelets (ASA, Warfarin, Heparin, ect...) because they may bleed

allot!! (learned that the hard way one) Now a unsecured airways is full of blood =(

3. CVA pt. who may be in the window for TPA, ect..... They will bleed once the clot is busted from everywhere

a laceration is. =(

Thanks,

David

There is alot of dissention and ?'s regarding the accuracy of your #1, also with entubation.

I am wuite sure that #2 and 3 are relative....

out here,

Ace844

[PRPGfirerescuetech]

There is alot of dissention and ?'s regarding the accuracy of your #1, also with entubation.

I am wuite sure that #2 and 3 are relative....

out here,

Ace844

All three are not relative, the discussion previously quoted NPS contra-indications, which all of these could be considered to be.

PRPG

[Ace844]

All three are not relative, the discussion previously quoted NPS contra-indications, which all of these could be considered to be.

PRPG

"PRPG,"

As you're an astute individual I am surprised that you are unaware of the literature concerning Naso-tracheal intubation in "head trauma" showing that it is beyon statistically unlikely that an naso-tracheal placed tube will infact be placed "in the cranial" cavity... The majority of that teaching is entrenched dogma that was seen in approx 2 isolated cases long ago. We had a discussion about this here some time ago and if anyone has a link handy feel free to post it..

So with the evidence and literature in mind if it is unlikely that a "rigid" endotracheal tube is unlikely to be placed in the "itra cranial cavity" I find it beyond ludricris to assume that a very "flexible" rubber/pvc hose will penetrate the anatomy on it's own... JMHLO!!!

As far as #2,3, well I am sorry to say this, but the need for AIRWAY ADEQUACY, PATENCY, @ PROTECTION surpasses "bleeding" in every treatment algorhythmn, piece of literature and education I have ever attended. Think A as in airway and it being 1st!!!! thus the other's are "relative" contrindications, and considerations....

Hope this helps,

Ace844

[PRPGfirerescuetech]

"PRPG,"

As you're an astute individual I am surprised that you are unaware of the literature concerning Naso-tracheal intubation in "head trauma" showing that it is beyon statistically unlikely that an naso-tracheal placed tube will infact be placed "in the cranial" cavity... The majority of that teaching is entrenched dogma that was seen in approx 2 isolated cases long ago. We had a discussion about this here some time ago and if anyone has a link handy feel free to post it..

So with the evidence and literature in mind if it is unlikely that a "rigid" endotracheal tube is unlikely to be placed in the "itra cranial cavity" I find it beyond ludricris to assume that a very "flexible" rubber/pvc hose will penetrate the anatomy on it's own... JMHLO!!!

As far as #2,3, well I am sorry to say this, but the need for AIRWAY ADEQUACY, PATENCY, @ PROTECTION surpasses "bleeding" in every treatment algorhythmn, piece of literature and education I have ever attended. Think A as in airway and it being 1st!!!! thus the other's are "relative" contrindications, and considerations....

Hope this helps,

Ace844

"Ace"

First, I appreciate the compliment. Second, you bring up some great points. I have always enjoyed the intellectual and well contructed posts youve brought...

Now to the task at hand...

I agree with all of your statements. If you refer to my posts careful wording, it states "could be considered to be"

Referring to #1 - As much as your correct with your statements regarding unlikely anatomy penetration through NPA usage in basal skull fractures, basal skull fractures are still taught as a contra indictation for NPA usage. Until the standard changes, a basal skull fx is still considered as such. As we all know, to vary from the standard of care is a huge liability. To change a standard, we have appropriate channels, and we need to adhere to that.

So is it a contra indictation, yes. Should it be, no. Which was the reasoning for my careful wording.

Referring to #2 and #3 - Your right again. When it comes down to it, Airway is first. But...(yes, their is always a but)

You still have to take bleeding into consideration with airway in these circumstances that if bleeding does occur, specifically

the originally cited examples. This person was correct, although im fairly sure he didnt realize it.

If an NPA is placed, and a laceration occurs in the aforementioned cirtcumstances, the subsequent blood in the airway is less a bleeding problem (the "b" in ABC) and more a airway problem (the "A" in ABC) acting similarly to an airway obstruction...

So, to close...my mistake was not the reading, but instead my wording. The bleeding that can occur is less a contra-indication and more a consideration prior to placement.

and as a side note, is it me, or do you have to have severely misjudged the NPA size prior to placement to cause the kind of damage that poster seems to reference? This was my biggest question...

That is all.....PRPG

[Ridryder 911]

Actually the danger lies in the soft portion of the sphenoid bone. Dr. John Shea a nuerosurgeon and very pro-EMS advocate, has attempting to eduae the dangers of C-spine and dangers of nasal intubation on potential head injury patients for years. That is why his medics performed crich in lieu of intubation on trauma patients.

There are more than 2 citations of brain stem intubations as well as NG tube placement in the brain stem, this however; should not be confused with the nasalpharnygeal airway which is very soft pliable and if measured properly does not extend past the nasal/oropharyngeal vault. Again, proper insertion with lubricating jelly and proper size makes this an excellant airway device in many patients.

I get very discouraged of how many EMS medics bring patients (especially CVA) without any airway device, yes, even conscious patients tolerate these well.

Be safe,

Ridryder 911

[Ace844]

"Ace"

First, I appreciate the compliment. Second, you bring up some great points. I have always enjoyed the intellectual and well contructed posts youve brought...

Now to the task at hand...

I agree with all of your statements. If you refer to my posts careful wording, it states "could be considered to be"

Referring to #1 - As much as your correct with your statements regarding unlikely anatomy penetration through NPA usage in basal skull fractures, basal skull fractures are still taught as a contra indictation for NPA usage. Until the standard changes, a basal skull fx is still considered as such. As we all know, to vary from the standard of care is a huge liability. To change a standard, we have appropriate channels, and we need to adhere to that.

So is it a contra indictation, yes. Should it be, no. Which was the reasoning for my careful wording.

Referring to #2 and #3 - Your right again. When it comes down to it, Airway is first. But...(yes, their is always a but)

You still have to take bleeding into consideration with airway in these circumstances that if bleeding does occur, specifically

the originally cited examples. This person was correct, although im fairly sure he didnt realize it.

If an NPA is placed, and a laceration occurs in the aforementioned cirtcumstances, the subsequent blood in the airway is less a bleeding problem (the "b" in ABC) and more a airway problem (the "A" in ABC) acting similarly to an airway obstruction...

So, to close...my mistake was not the reading, but instead my wording. The bleeding that can occur is less a contra-indication and more a consideration prior to placement.

and as a side note, is it me, or do you have to have severely misjudged the NPA size prior to placement to cause the kind of damage that poster seems to reference? This was my biggest question...

That is all.....PRPG

"PRPG",

Duely noted, I agree and I missed the ' "could be considered to be" ' part of the post..I apologize, and agree with you in all of your above points..

As for your sidenote, I guess one can consider that in some ways where an airway is concerned you could use the philsophy that "bigger is better" within the realm that it will actually fit where it is "being placed".....Umm.... on second though perhaps that will take us to a place we don't need to go and be grossly misunderstood......!?!?!?

Lastly, you wrote;

"the subsequent blood in the airway is less a bleeding problem (the "b" in ABC) and more a airway problem (the "A" in ABC) acting similarly to an airway obstruction..."

[Ace844]

Actually the danger lies in the soft portion of the sphenoid bone. Dr. John Shea a nuerosurgeon and very pro-EMS advocate, has attempting to eduae the dangers of C-spine and dangers of nasal intubation on potential head injury patients for years. That is why his medics performed crich in lieu of intubation on trauma patients.

There are more than 2 citations of brain stem intubations as well as NG tube placement in the brain stem, this however; should not be confused with the nasalpharnygeal airway which is very soft pliable and if measured properly does not extend past the nasal/oropharyngeal vault. Again, proper insertion with lubricating jelly and proper size makes this an excellant airway device in many patients.

I get very discouraged of how many EMS medics bring patients (especially CVA) without any airway device, yes, even conscious patients tolerate these well.

Be safe,

Ridryder 911

"Rid," ok, perhaps the number is greater than 2, and it may be larger like 3, but you have to admit the preponderence of the literature most noteably/recently these from CO and WA where they performed a multi-year/ center trial of pre-hospital nasotracheal entubations WITHOUT any intracrainal placements as well as a number of "in house" studyies essentially validating the same conclusions, or perhaps I'm missing some important pieces out there?!!? Also, the cases which are always quoted for this took place in the late 70's @early 80's, it seems that much like the entrenched DOGMA of ACLS we will be haunted by this for many years to come... There was even a Chorcrane review article about a year and a half ago on this very subject..Either way for the record, I don't usually make it a habit to confuse endotracheal tubes and NPA's, that gets embarrassing VERY QUICKLY!

out here,

Ace844

[PRPGfirerescuetech]

"Ace"

First, I appreciate the compliment. Second, you bring up some great points. I have always enjoyed the intellectual and well contructed posts youve brought...

Now to the task at hand...

I agree with all of your statements. If you refer to my posts careful wording, it states "could be considered to be"

Referring to #1 - As much as your correct with your statements regarding unlikely anatomy penetration through NPA usage in basal skull fractures, basal skull fractures are still taught as a contra indictation for NPA usage. Until the standard changes, a basal skull fx is still considered as such. As we all know, to vary from the standard of care is a huge liability. To change a standard, we have appropriate channels, and we need to adhere to that.

So is it a contra indictation, yes. Should it be, no. Which was the reasoning for my careful wording.

Referring to #2 and #3 - Your right again. When it comes down to it, Airway is first. But...(yes, their is always a but)

You still have to take bleeding into consideration with airway in these circumstances that if bleeding does occur, specifically

the originally cited examples. This person was correct, although im fairly sure he didnt realize it.

If an NPA is placed, and a laceration occurs in the aforementioned cirtcumstances, the subsequent blood in the airway is less a bleeding problem (the "b" in ABC) and more a airway problem (the "A" in ABC) acting similarly to an airway obstruction...

So, to close...my mistake was not the reading, but instead my wording. The bleeding that can occur is less a contra-indication and more a consideration prior to placement.

and as a side note, is it me, or do you have to have severely misjudged the NPA size prior to placement to cause the kind of damage that poster seems to reference? This was my biggest question...

That is all.....PRPG

"PRPG",

Duely noted, I agree and I missed the ' "could be considered to be" ' part of the post..I apologize, and agree with you in all of your above points..

As for your sidenote, I guess one can consider that in some ways where an airway is concerned you could use the philsophy that "bigger is better" within the realm that it will actually fit where it is "being placed".....Umm.... on second though perhaps that will take us to a place we don't need to go and be grossly misunderstood......!?!?!?

Lastly, you wrote;

"the subsequent blood in the airway is less a bleeding problem (the "b" in ABC) and more a airway problem (the "A" in ABC) acting similarly to an airway obstruction..."

2 hours sleep in 3 days does this kind of thing.

A: Airway

B: Breathing

C: Circulation

C would have been the appropriate reference...oops.....

prpg

[DartmouthDave]

Hello,

I didn't mean to irk so many people with my post.

The area in which I work is very particular about anything in the nose for Basal Skull fracture.

Also, I saw an NPA inserted in a pt with a decreased loc, and low stas ect... who bleed profoundly and

aspirated a ton of blood. Of course, unknown to those inserting the NPA was the fact that

she had mechanical heart valves, had been taking too much Warfarin (her INR was very high) and

had very high BP.

I work at a major stroke ctr that covers a large geographic area, and a couple of times pt

got bad epitaxis from NPA post TPA infusions causing some grief.

When reading the posts these couple of cases came to mind. Just points to ponder when you open the airway

bag and the OPA and NPA are looking back at you. (and with any luck, prevent some grief at work)

David

[Ridryder 911]

I agree, nasal intubation can be & should be considered on some patients. I believe actually the number of cranial intubations may be a couple a year; but due to litigation and law suits the true number may not be ever disclosed. I do believe in nasal intubation if possible and allowable if their again is no chance of facial fractures such as La Forte or suspected basilar fxr. This is why I am big proponent of RSI.

Be safe,

Ridryder 911