OPA/NPA trauma question

[Lisa DiMambro]

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

 

[STXmedic]

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).

 

[Carlos Danger]

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.

 

[Brandon O]

LMA's should not be used to deliver positive pressure

Say what now?

 

[Carlos Danger]

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.

 

[Brandon O]

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?

 

[Carlos Danger]

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.

 

[Brandon O]

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.

 

[Carlos Danger]

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.

 

[Brandon O]

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

 

[Carlos Danger]

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.

 

[Brandon O]

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

 

[Carlos Danger]

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.

 

[Tigger]

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 .

 

[Brandon O]

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.

 

[Carlos Danger]

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).

 

[Carlos Danger]

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.

 

[Brandon O]

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?

 

[Chewy20]

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.

 

[NomadicMedic]

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