PDA

View Full Version : NPAs in PACOM/shopping in VA Beach


Defend
07-28-2014, 20:55
All,

Currently refitting/upgrading my M3 for current AO. I'm wondering what the PACOM experienced docs recommend for sizing nasopharyngeal airways in Asian patients.

-out

Brush Okie
07-28-2014, 21:44
Try to Google "sizing an NPA" there is no adult size, Asian size etc. Get training before you use one. Using one under wrong conditions is a bad bad thing and can kill someone.

Defend
07-29-2014, 00:27
Thanks for the word of caution, but in my case I am CLS certified, I don't carry anything I'm not trained on and comfortable using, and I have successfully employed that training downrange when it meant life or death.

To clarify the question, I'm looking for some recommended guidelines for selecting NPA gauge. My training has all been on fellow male service members using 28fr airways, and that's what I carry in my IFAK and in my M3 kit should I need it for a team member.

In my specific AO, as in most of Asia, adults are about 5'4 - 5'8 and smaller framed than the average GI. I know the guidelines for how far to insert, but I'm looking for somebody more experienced than I in this part of the world who can give some advice on what gauges to carry here. I don't want to get caught in a situation where a pt needs it so I can focus on more than the airway, and can't get it in because I didn't come prepared.

-out

Brush Okie
07-29-2014, 00:56
delet

Defend
07-29-2014, 02:26
I'm going to assume that my response must have come across as arrogant or abrasive in order to elicit your response, so first off, neither of those tones were intended. You were blunt, so I'll be blunt in return but please realize I respect your experience and cautions, but you're being very quick to assume and condemn.

1) I Googled the issue prior to posting anything, and read some great material including this article (http://emj.bmj.com/content/22/6/394.long) from the Emergency Medicine Journal - which discusses in some level of detail many of your concerns (which is also included in the CLS material). It didn't answer the question I had - which is an AO specific experience based question (see #3 for why in my case this is AO specific). And yes, I am familiar with indications and contraindications, how to place the bevel, nostril selection, etc etc. Can I explain it in the level of detail you can? probably not - I'm not a medic. Can I properly employ the technique and save a comrade who is bleeding out while I try to keep his airway open? Hell yes I can.

2) I'M not impressed with CLS, and I certainly don't expect you to be - it's nothing more than a starting point. However, I know at least one guy I worked on solo who is still alive today because of that starting point. Ironically, he did have contraindications to an NPA, so I didn't even pull mine out. And yes, I'm sure you've seen more trauma in a day than I have in any tour.

3) This was not intended to be a controversial post. I'm just a PSYOP guy who covers down on commo on civilian mobs, carries a ton of gear, and is not always by a medics side, and has very limited supply chains. I don't have the luxury of hauling one of everything every day, and I know I'm not the first in these shoes in this region. That's why I asked for advice on what to stock my kit with.

4) I have the rare privilege of being along side my wife down range. I don't carry anything I am not confident enough in to use on her. Which leads me to my next point -


Since you are to lazy to google it yourself here I did it for you just so you don't kill anyone. I am doing it for them not you.

5) Please don't accuse me of being lazy, or suggest that without your post I would have killed somebody. You took it to personal attacks there that were unnecessary and inaccurate. I made it clear in my first response that I don't carry anything I'm not trained and proficient on. I've done my research, had a clarifying question, and asked.

I've learned a lot from reading your posts over nearly the last six years and respect you for your knowledge, but I'm not appreciative of your unfounded attack on my character and professionalism.

I think this thread has traveled it's due course - which wasn't at all where I intended it to go and honestly I don't see much use for. Mods, unless there is something productive to be done here can you shut it down?

-out

Surgicalcric
07-29-2014, 02:28
Defend:

In years past NPAs were sized according to the patients pinky finger first then trimmed to fit the length and while that got us by and will still do the trick in a pinch. Quite a bit of research on the civilian sector suggests that diameter isnt near as important as the length. As we know a correctly placed NPA will lie just above the epiglottis having separated the soft palate from the posterior wall of the oropharynx. But if the airway is too short it will fail to separate the soft palate from the pharynx and if too long it can either pass into the larynx and aggravate cough and gag reflexes or pass anterior to the epiglottis into the vallecula, a blind ending pouch, where paradoxical airway obstruction can occur if the NPA lumen is pressed against the soft tissues. This distance is the approximate length from the tip of nostril to the ear lobe.

So with that knowledge a conscientious and pragmatic medical provider such as yourself you would need to select a range to carry. With space at a premium in most medic/aid bags, especially an M3, I would limit myself to carrying two for average patient size based on your AO and one each from the other ranges: 18fr for smaller adult (usually females), 24fr for average frame adults and 27fr for larger adults. Since your AO will primarily include a shorter than average (US) patient height then choose to carry two 18fr NPAs and one each from the other two.


What questions do you have now?

Crip


<<SNIP>>

Both of your replies were condescending towards the OP so how about you drop the arrogance. If you arent capable of helping out others without being an ass dont hit the "Submit Reply" button.

Defend
07-29-2014, 03:38
Surgicalcric,

Thanks!

Only other question is can anybody recommend a military friendly medical supply shop to do business with in the Hampton Roads area? I intended to ask that in the original post but it looks like it didn't make it past the subject line...:rolleyes:.

-out

PedOncoDoc
07-29-2014, 08:00
Quite a bit of research on the civilian sector suggests that diameter isnt near as important as the length.

That's what she said. :p

So with that knowledge a conscientious and pragmatic medical provider such as yourself you would need to select a range to carry. With space at a premium in most medic/aid bags, especially an M3, I would limit myself to carrying two for average patient size based on your AO and one each from the other ranges: 18fr for smaller adult (usually females), 24fr for average frame adults and 27fr for larger adults. Since your AO will primarily include a shorter than average (US) patient height then choose to carry two 18fr NPAs and one each from the other two.

On a more serious note - looking at this list I do not see any recommendation for an airway for children in the aid bag. I'm curious to hear your thoughts on this, given your experience and expertise.

Brush Okie
07-29-2014, 09:58
I'm going to assume that my response must have come across as arrogant or abrasive in order to elicit your response, so first off, neither of those tones were intended. You were blunt, so I'll be blunt in return but please realize I respect your experience and cautions, but you're being very quick to assume and condemn.

1) I Googled the issue prior to posting anything, and read some great material including this article (http://emj.bmj.com/content/22/6/394.long) from the Emergency Medicine Journal - which discusses in some level of detail many of your concerns (which is also included in the CLS material). It didn't answer the question I had - which is an AO specific experience based question (see #3 for why in my case this is AO specific). And yes, I am familiar with indications and contraindications, how to place the bevel, nostril selection, etc etc. Can I explain it in the level of detail you can? probably not - I'm not a medic. Can I properly employ the technique and save a comrade who is bleeding out while I try to keep his airway open? Hell yes I can.

2) I'M not impressed with CLS, and I certainly don't expect you to be - it's nothing more than a starting point. However, I know at least one guy I worked on solo who is still alive today because of that starting point. Ironically, he did have contraindications to an NPA, so I didn't even pull mine out. And yes, I'm sure you've seen more trauma in a day than I have in any tour.

3) This was not intended to be a controversial post. I'm just a PSYOP guy who covers down on commo on civilian mobs, carries a ton of gear, and is not always by a medics side, and has very limited supply chains. I don't have the luxury of hauling one of everything every day, and I know I'm not the first in these shoes in this region. That's why I asked for advice on what to stock my kit with.

4) I have the rare privilege of being along side my wife down range. I don't carry anything I am not confident enough in to use on her. Which leads me to my next point -



5) Please don't accuse me of being lazy, or suggest that without your post I would have killed somebody. You took it to personal attacks there that were unnecessary and inaccurate. I made it clear in my first response that I don't carry anything I'm not trained and proficient on. I've done my research, had a clarifying question, and asked.

I've learned a lot from reading your posts over nearly the last six years and respect you for your knowledge, but I'm not appreciative of your unfounded attack on my character and professionalism.

I think this thread has traveled it's due course - which wasn't at all where I intended it to go and honestly I don't see much use for. Mods, unless there is something productive to be done here can you shut it down?

-out

I apologize I read you wrong. I have seen 1/2 trained volunteer firefighters almost kill people because they did not know what they were doing. While well meaning the patient is still dead.

Long story short if you have an NPA that is too long they can kick the gag reflex into action, they puke and drown on their own vomit or get pneumonia and die. That is why it is critical to have to correct length. Too short it does not work. I went to a CLS class and some of the info they gave was well dangerous.

A trick to check gag reflex on a unconscious pt is to flick their eye lashed. Some people have a gag reflex when out. If they react to the eye lash touch then they have a gag reflex.

Surgicalcric
07-29-2014, 10:22
...On a more serious note - looking at this list I do not see any recommendation for an airway for children in the aid bag. I'm curious to hear your thoughts on this, given your experience and expertise.

Your question is one of triage at the root of it and so the decision on who and how many gets treated for "X" injuries occurs long before the first rotor or tire rolls out of the gate. As harsh as it sounds we can't carry everything for everyone so we carry supplies based on injuries expected over the largest demographic of patients. Triage truly should begin with patient demographic analysis (US, coalition, civilian - adult vs pediatric, enemy personnel) of the AO or target area. I am not talking about pulling up complex consensus reports but looking at places of worship or schools in or around the target area(s) and population density. If I am concerned about a high possibility of taking pediatric casualties I will toss a pediatric specific pouch in my extended care/evac bag but I don't usually carry any pediatric stuff in my assault bag. Pediatric specific supplies in my bag include airways: NPA & cuffed ETT for crics, IV cannulas and a buretrol, and a dosing chart tethered to the pouch.

As for CLS trained personnel and pediatric patients, MOO based on previous interaction with some is if there are casualties a CLS guys time would be much better spent working on the patient populace in which they trained instead of "winging it". I don't agree with the axiom that peds are little adults and get treated accordingly.

Hope that addresses your question.

Crip

Surgicalcric
07-29-2014, 10:47
A trick to check gag reflex on a unconscious pt is to flick their eye lashed. Some people have a gag reflex when out. If they react to the eye lash touch then they have a gag reflex.

Speaking of half trained...that is incorrect.

The Facial Nerve (CN V) mediates the corneal (eyelash) reflex and the gag reflex is mediated by the Glossopharyngeal and Vagus (CNs IX and X) nerves. These nerves do not share any common pathways and the presence of one does not imply anything about the other. Anesthesiologists often times will utilize the method you outlined to gauge alteration in gross sensory function from a known baseline. There is a correlation (although not perfect) between unconsciousness and loss of gag, so there is some value in the lash test for that but using it in the field while suggestive, isn't the same.

The history of the lash test is that in the OR after administration of an induction agent, the anesthesiologist would lightly brush the eyelashes to check for a blink. The reasoning behind this practice is not so much to check for a gag (going to make that go AWAY!) but to check for unconsciousness prior to the administration of a neuromuscular blocking agent. If no blink is present, the anesthesiologist could be reasonably certain they were not paralyzing a patient who is "awake".

Brush Okie
07-29-2014, 10:55
Speaking of half trained...that is incorrect.

The Facial Nerve (CN V) mediates the corneal (eyelash) reflex and the gag reflex is mediated by the Glossopharyngeal and Vagus (CNs IX and X) nerves. These nerves do not share any common pathways and the presence of one does not imply anything about the other. Anesthesiologists often times will utilize the method you outlined to gauge alteration in gross sensory function from a known baseline. Using it in the field while suggestive, isn't the same.

Thanks for the clarification. I had someone tell me that years ago.

Surgicalcric
07-29-2014, 11:22
Thanks for the clarification. I had someone tell me that years ago.

Trust but verify.

Don't pass on anecdotal info as fact, especially on topics pertaining to emergency/trauma medicine. There is no room for that not to mention it dings your credibility, especially given your previous comments about volunteer firefighters. ;)

Surgicalcric
07-29-2014, 11:26
Surgicalcric,

Thanks!

Only other question is can anybody recommend a military friendly medical supply shop to do business with in the Hampton Roads area?

-out

I don't. Most of my stuff comes from online companies. Have you tried the intraweb for what you need? And what do you mean "military friendly," discounts?

Brush Okie
07-29-2014, 11:28
Trust but verify.

Don't pass on anecdotal info as fact, especially on topics pertaining to emergency/trauma medicine. There is no room for that not to mention it dings your credibility, especially given your previous comments about volunteer firefighters. ;)

Will do, it was higher medical authority that told me that. I sent a PM for clarification so as not to come off as an ass again.

Surgicalcric
07-29-2014, 12:07
Will do, it was higher medical authority that told me that. I sent a PM for clarification so as not to come off as an ass again.

Totally understand.

This board is about passing on knowledge and education. Most all have an "I heard" story that has come back to bite us in the ass at some point.

As I explained earlier, the eyelash test is probably one of those, "well I saw it used in the OR and I am fairly certain it was test before intubation so it must be for the gag reflex" kinda things that just happens to work successfully most of the time due to a close correlation.

Tongue depressors are invaluable.

Defend
07-29-2014, 12:21
I apologize I read you wrong. I have seen 1/2 trained volunteer firefighters almost kill people because they did not know what they were doing. While well meaning the patient is still dead.

Thanks Okie, we're all good.

I don't. Most of my stuff comes from online companies. Have you tried the intraweb for what you need? And what do you mean "military friendly," discounts?

Discounts are great, but I was leaning more in the direction of catering to military audiences in what they stock. Even for simple products I'm still a fan of buying in person, making that face to face connection. And it's always nice to see cool new gear :cool:.

I've been looking on Amazon, nothing wrong with what I'm seeing although the only assorted packs I found are huge, starting at 28fr and going up. If you have a preferred online supplier please share - I didn't see that elsewhere on here with my searchfu but may have missed it.

BTW lots of great info in the last grouping of posts, thanks all. In lieu of Brush Okie's trick for detecting gag reflex, is there anything that works other than trial/error?

-out

PedOncoDoc
07-29-2014, 12:22
Your question is one of triage at the root of it and so the decision on who and how many gets treated for "X" injuries occurs long before the first rotor or tire rolls out of the gate. As harsh as it sounds we can't carry everything for everyone so we carry supplies based on injuries expected over the largest demographic of patients. Triage truly should begin with patient demographic analysis (US, coalition, civilian - adult vs pediatric, enemy personnel) of the AO or target area. I am not talking about pulling up complex consensus reports but looking at places of worship or schools in or around the target area(s) and population density. If I am concerned about a high possibility of taking pediatric casualties I will toss a pediatric specific pouch in my extended care/evac bag but I don't usually carry any pediatric stuff in my assault bag. Pediatric specific supplies in my bag include airways: NPA & cuffed ETT for crics, IV cannulas and a buretrol, and a dosing chart tethered to the pouch.

As for CLS trained personnel and pediatric patients, MOO based on previous interaction with some is if there are casualties a CLS guys time would be much better spent working on the patient populace in which they trained instead of "winging it". I don't agree with the axiom that peds are little adults and get treated accordingly.

Hope that addresses your question.

Crip

Thanks Crip-

It's good to hear that you prepare for potential pediatric casualties if children are expected in the AO.

I firm thumbs up and agreement from me regarding "Children are not just little adults" physiologically, anatomically or otherwise.

One would think that tended to pediatric causalties would help with winning over hearts and minds of the current generation and the next...

DDD
07-29-2014, 13:18
Online checkout rescue essentials. User friendly, competitive prices.

Doczilla
09-29-2014, 10:48
Only other question is can anybody recommend a military friendly medical supply shop to do business with in the Hampton Roads area?

I agree with others about online retailers. North American Rescue Products, Tactical Medical Solutions, Chinook Med to name a few that I've had good dealings with.

steel_eel
09-29-2014, 23:39
Only other question is can anybody recommend a military friendly medical supply shop to do business with in the Hampton Roads area?

Have you checked out Double Tap Surplus? They mostly have hemorrage control items but it wouldn't surprise me if they have NPAs/Airway items now.

Stephens
11-16-2014, 14:30
Speaking of half trained...that is incorrect.

The Facial Nerve (CN V) mediates the corneal (eyelash) reflex and the gag reflex is mediated by the Glossopharyngeal and Vagus (CNs IX and X) nerves. These nerves do not share any common pathways and the presence of one does not imply anything about the other. Anesthesiologists often times will utilize the method you outlined to gauge alteration in gross sensory function from a known baseline. There is a correlation (although not perfect) between unconsciousness and loss of gag, so there is some value in the lash test for that but using it in the field while suggestive, isn't the same.

The history of the lash test is that in the OR after administration of an induction agent, the anesthesiologist would lightly brush the eyelashes to check for a blink. The reasoning behind this practice is not so much to check for a gag (going to make that go AWAY!) but to check for unconsciousness prior to the administration of a neuromuscular blocking agent. If no blink is present, the anesthesiologist could be reasonably certain they were not paralyzing a patient who is "awake".

IMO, Some Excellent info from SurgicalCric. Also, I feel Okie is correct in advising caution to anyone using an NPA---especially in the field where things are much less controlled than in the OR.

This is true. We induce and then brush eyelash for reflex, then tape eye shut.
It's to answer the question "is this guy asleep?" Tape eyes. Muscle relaxant.

And yes, a NPA in a pt who is not deep enough can provoke brutal
Vomiting
Laryngospasm
Bleeding

Ask me how I know. :( Years ago, I had one huge guy I put a NPA in immediately valsalva and shoot a huge stream of green battery acid out of the NPA. He did fine but he could have aspirated and died.

I put an NPA in a lady in the OR once and she immediately started gushing blood. Turns out she had a history of terrible nose bleeds. I didn't ask her about that pre-op and frankly never expected to need an NPA for her--but I stupidly pulled the trigger and paid the price. She did fine with afrin and elevating her head but it slowed the case down.

Learn from my mistakes.
Take home;
They work great but I hesitate to pull the trigger on one unless I have to.
I've been in anesthesia (nurse) 10 years and an NPA will scare me.
I have low threshold for aborting insertion attempt if it isn't smooth as butter.

NurseTim
11-17-2014, 19:02
IMO, Some Excellent info from SurgicalCric. Also, I feel Okie is correct in advising caution to anyone using an NPA---especially in the field where things are much less controlled than in the OR.

This is true. We induce and then brush eyelash for reflex, then tape eye shut.
It's to answer the question "is this guy asleep?" Tape eyes. Muscle relaxant.

And yes, a NPA in a pt who is not deep enough can provoke brutal
Vomiting
Laryngospasm
Bleeding

Ask me how I know. :( Years ago, I had one huge guy I put a NPA in immediately valsalva and shoot a huge stream of green battery acid out of the NPA. He did fine but he could have aspirated and died.

I put an NPA in a lady in the OR once and she immediately started gushing blood. Turns out she had a history of terrible nose bleeds. I didn't ask her about that pre-op and frankly never expected to need an NPA for her--but I stupidly pulled the trigger and paid the price. She did fine with afrin and elevating her head but it slowed the case down.

Learn from my mistakes.
Take home;
They work great but I hesitate to pull the trigger on one unless I have to.
I've been in anesthesia (nurse) 10 years and an NPA will scare me.
I have low threshold for aborting insertion attempt if it isn't smooth as butter.

Would retreating with neosynphrine (spelling?) have prevented this? The bold portion I mean.

Brush Okie
11-17-2014, 19:12
I

And yes, a NPA in a pt who is not deep enough can provoke brutal
Vomiting
Laryngospasm
Bleeding

Ask me how I know. :(

Sounds like you learned the same way I did.

Stephens
11-18-2014, 20:45
Would retreating with neosynphrine (spelling?) have prevented this? The bold portion I mean.


For most patients, it can make a huge difference (Neo syenephrine or afrin).
This lady was a special case--history of bad nose bleeds.
We did use afrin on her prior to insertion but wasn't enough.

Stephens
11-18-2014, 20:55
Sounds like you learned the same way I did.


Yes. The hard way.
NPA is worth it when your back is against the wall.
But I never force them--
Give afrin (BOTH nostrils)
Wait
Wait
Gently attempt insertion-rotating as needed, seeking the best angle
If no go, try the other nostril.