can someone advise on which airways to use in unconscious patients? Watch

Anonymous #1
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My friend told if GCS below 8 they would need intubating. Therefore would need to fast bleep anaesthetist. Is this accurate? If not below 8 which is preferable OPA or NPA?
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Anonymous #1
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and really stupid q but can someone pleas define a non patent airway and therefore when I would insert an airway adjunct
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Anonymous #1
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and how long do you wait before someone is non responsive before you insert one?
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Etomidate
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It really depends on the circumstance, the skills that you have to hand and the people you expect to attend and in what time frame.

A non-patent airway has a number of signs which range from partial obstruction to complete obstruction. You don't necessarily have to have a reduced GCS to have an obstructed airway (think choking, bleeding, haematomas post-op).

A partially obstructed airway might cause snoring noises. This could be potentially solved with simple head/jaw maneuvers. Equally you can pop in an OPA and/or an NPA. They both have pros and cons, but whatever you're comfortable with. Also keep in mind that this does not = a secure airway!

A completely obstructed airway might be silent. You may also see paradoxical movements of the chest/abdo or absent misting within the mask/tubing.

How long you wait is again circumstantial. At the end of the day, an adjunct is an adjunct. Just pop one in. If they spit it out, so be it.

Less than 8, intubate is a good rule of thumb but by no means gospel.
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Helenia
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(Original post by Anonymous)
My friend told if GCS below 8 they would need intubating. Therefore would need to fast bleep anaesthetist. Is this accurate? If not below 8 which is preferable OPA or NPA?
(Original post by Anonymous)
and really stupid q but can someone pleas define a non patent airway and therefore when I would insert an airway adjunct
If you fast bleep the anaesthetist for every GCS <8 without attempting to engage your brain first, you will not win friends. A basic airway assessment is a core skill for every doctor. I'm not aware of an official definition of "non-patent airway" - it just is what it sounds like. If the air is not going in and out, the airway is not patent. There is also a difference between "not patent" and "not protected" - the former being a considerably greater emergency than the latter. Look at the patient. Are they making respiratory effort? Can you hear air going in and out or see misting on a face mask? If you're in ED, many units now have bedside capnography in resus which will give you a more definite answer. Can you hear any gurgling or snoring noises? These are concerning, but more reassuring than someone who is not shifting any air at all.

Sit the patient up a little - properly, making sure their body is far enough up the bed IYSWIM. Position their head on one or two pillows, in a slightly extended posture. Stick oxygen on. If you're still not sure about the airway, do a jaw thrust (this is also a good test of their GCS!) and/or put in an adjunct. NPAs tend to be better tolerated than OPAs in all but the most deeply unconscious patients. Get some obs, including a sats reading, and continue your ABC assessment. If vomiting is likely (e.g. EtOH excess) then you may want to consider putting them on their side instead.

And the other key thing is, WHY is their GCS low/airway not protected? The management that the anaesthetist will initiate, and how scared WE get, will vary widely depending on this - someone with acute epiglottitis who has a GCS of 15 but is drooling and sounds like Mickey Mouse is FAR more concerning than a pissed patient with low GCS. If you can think of a likely cause, start investigating/treating. By all means call the anaesthetist, and if the airway is genuinely completely obstructed and they are desaturating, fast bleep them (or put out a crash call, because it will turn into one v soon), but otherwise a brief assessment and initial management is usually a good idea.
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Anonymous #1
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(Original post by Helenia)
If you fast bleep the anaesthetist for every GCS <8 without attempting to engage your brain first, you will not win friends. A basic airway assessment is a core skill for every doctor. I'm not aware of an official definition of "non-patent airway" - it just is what it sounds like. If the air is not going in and out, the airway is not patent. There is also a difference between "not patent" and "not protected" - the former being a considerably greater emergency than the latter. Look at the patient. Are they making respiratory effort? Can you hear air going in and out or see misting on a face mask? If you're in ED, many units now have bedside capnography in resus which will give you a more definite answer. Can you hear any gurgling or snoring noises? These are concerning, but more reassuring than someone who is not shifting any air at all.

Sit the patient up a little - properly, making sure their body is far enough up the bed IYSWIM. Position their head on one or two pillows, in a slightly extended posture. Stick oxygen on. If you're still not sure about the airway, do a jaw thrust (this is also a good test of their GCS!) and/or put in an adjunct. NPAs tend to be better tolerated than OPAs in all but the most deeply unconscious patients. Get some obs, including a sats reading, and continue your ABC assessment. If vomiting is likely (e.g. EtOH excess) then you may want to consider putting them on their side instead.

And the other key thing is, WHY is their GCS low/airway not protected? The management that the anaesthetist will initiate, and how scared WE get, will vary widely depending on this - someone with acute epiglottitis who has a GCS of 15 but is drooling and sounds like Mickey Mouse is FAR more concerning than a pissed patient with low GCS. If you can think of a likely cause, start investigating/treating. By all means call the anaesthetist, and if the airway is genuinely completely obstructed and they are desaturating, fast bleep them (or put out a crash call, because it will turn into one v soon), but otherwise a brief assessment and initial management is usually a good idea.
SO helpful. Thanks.
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Anonymous #1
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(Original post by Etomidate)
It really depends on the circumstance, the skills that you have to hand and the people you expect to attend and in what time frame.

A non-patent airway has a number of signs which range from partial obstruction to complete obstruction. You don't necessarily have to have a reduced GCS to have an obstructed airway (think choking, bleeding, haematomas post-op).

A partially obstructed airway might cause snoring noises. This could be potentially solved with simple head/jaw maneuvers. Equally you can pop in an OPA and/or an NPA. They both have pros and cons, but whatever you're comfortable with. Also keep in mind that this does not = a secure airway!

A completely obstructed airway might be silent. You may also see paradoxical movements of the chest/abdo or absent misting within the mask/tubing.

How long you wait is again circumstantial. At the end of the day, an adjunct is an adjunct. Just pop one in. If they spit it out, so be it.

Less than 8, intubate is a good rule of thumb but by no means gospel.
Thanks - literally never know whether to use NPA/OPA - never been in this situation but prepping ahead!
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Helenia
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(Original post by Anonymous)
Thanks - literally never know whether to use NPA/OPA - never been in this situation but prepping ahead!
Either, and if one doesn't work, try the other or both!
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InArduisFouette
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(Original post by Anonymous)
and really stupid q but can someone pleas define a non patent airway and therefore when I would insert an airway adjunct
A patent airway is one where the air / gas mixture can flow in and out without being impeded and/or dragging anything (salvia, mucus, vomit , blood etc ) further into the respiratory system

A 'self maintained' patent airway is what you or i most likely have as we are sitting here reading this thread ( i say most likely as there;s a likely hood that someone with trachy may be reading this )

Managing an airway goes back to the simplest first principles

- If you are faced with an unrousable patient , open their airway using a head tilt / chin lift as you will have been taught in your BLS / first aid class (unless there is a very very good reason not to )

- does this make their breathing sound better ?
i.e. was their tongue 'flopping' back over their airway ?

- In the ward / dept / anaesthetic setting is there anything in the mouth or pharynx that you could / should be thinking about removing with suction (nice big wide bore yankauer) / magills forceps?
- obviously if you have an airway completely full of 'stuff' postural drainage is far quicker and if there's a choice be at the head ( and therefore aiming ) or on the side 'away ' from where the patient is rolled ...

nasal airways may be tolerated better than oral airways if a patient has some level of gag reflex ...

realistically once you have intervened you are looking at having someone with the patient at all times at least in the short term ( the situation may change if the patient is a tlc only stroke patient for example ) and it's at this point you need to thinking about anaesthetic opinions / intubation

- again slightly different if you are a competent intubator and the situation presenting is such that intubation is a relevant option in which case.
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InArduisFouette
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(Original post by Helenia)
Either, and if one doesn't work, try the other or both!
OPAs work very well where tolerated

NPAs can be better tolerated in some cases and provide a good airway - peopel are scared ofthem due to the cautions related to facial and head trauma ...

i'm still PRSOM for Helenia
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nathan2k1
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can someone advise on which airways to use in unconscious patients?

Preferably the mouth Dr ABC.
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Helenia
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(Original post by zippyRN)
OPAs work very well where tolerated

NPAs can be better tolerated in some cases and provide a good airway - peopel are scared ofthem due to the cautions related to facial and head trauma ...

i'm still PRSOM for Helenia
Good point - if there is head trauma, particularly suspicion of basal skull #, or lots of nasal bleeding, NPAs are not suitable.
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