NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 5419

POLICIES AND PROCEDURES

Subject: Medical Direction

Associated Policies: 02/08/98

1. Indications:

1. To lavage the stomach.
2. To decompress the stomach.

2. Therapeutic Effects:

1. Evacuation of stomach contents.
2. When combined with activated charcoal, adsorption of ingested poisons and drugs.

3. Contraindications:

1. Absolute:

1. Suspected fractures of the basilar skull.
2. Facial trauma with suspected fractures.
3. Known or suspected esophageal varices.

1. Relative:

1. Ingestion of caustic poisons (tracheal intubation recommended prior).

4. Adverse Effects:

1. Passage of the tube into the trachea.
2. Coiling of the tube in the posterior pharynx.

5. Equipment:

1. Closed system gastric lavage tray or equivalent.
2. Ewald or other gastric evacuation tubes: Nasogastric sizes-5 French to 18 French, Orogastric sizes-24 French to 42 French.
3. Two (2) Normal Saline or Sterile Water in 1 L plastic containers.
4. Water soluble lubricant.
5. Tape or tube holder.
6. 60 ml irrigation syringe with catheter tip.
7. Emesis basin.
8. Stethoscope.

6. Procedure;

1. Determine the need for a NG or OG tube. Infants < 6 mos are nose breathers and an OG is preferred.
2. Determine correct size:

1. Pediatrics: Use Resuscitation tape.

• Nasogastric tubes can be used as Orogastric tubes in the pediatric patient.
• 8 French feeding tube may be substituted for nasogastric tube sizes 5/6 to 8 French.

1. Adults:

• Nasogastric: Largest tube that can pass through nare
• Orogastric: Largest tube that is needed to aspirate out substance or toxin from stomach.

1. Restrain the patient, as necessary.
2. Position patient:

1. Conscious patient, high fowlers with head tilted forward ("chin on chest").
2. Unconscious patient, left lateral recumbent position with slight Trendelenburg. Airway must be protected by endotracheal intubation prior to NG or OG placement.

1. Measure length of NG tube from the nose to the earlobe and then to a point midway between xyphoid process and umbilicus.
2. Mark the length of tube with a piece of tape.
3. Lubricate tip of tube with water soluble lubricant if inserting nasally.
4. Nasal insertion:

1. Direct tube along the floor of nostril to the posterior pharyngeal than direct the tube downward through the nasopharynx.

1. Oral insertion:

1. Direct tube to the back of the tongue and then direct tube downwards through the oropharynx.

1. If patient is conscious or old enough to follow instructions, instruct the patient to swallow to facilitate the placement of the tube in the stomach.
2. Continue advancing tube until tape mark is at the nostril or the lip.
3. If tube meets resistance or the patient has respiratory distress, remove the tube. Fogging of the tube accompanied by cough or respiratory distress indicates tracheal intubation.
4. If patient begins to vomit, suction around tube and leave in place.
5. Confirm placement of tube by:

1. Aspirating gastric contents with a syringe.
2. Injecting 5 to 20 cc of air while auscultating over the stomach for a "swoosh or a burp" indicating gastric placement.
3. Auscultate lung sounds.

1. If tube is not placed properly:

1. Remove immediately.
2. Reinsert following the same procedure.
3. Do not attempt insertion more than three (3) times.

1. If tube is properly placed:

1. Tape in place or apply a tube holder.

1. For stomach decompression:

1. Attach tube to continuous low suction.

1. For lavage:

1. Connect to closed lavage system.
2. Lavage gastric contents by:

1. Instilling 20 to 150 ml boluses of solution to maximum of 4 liters.
2. Then withdrawing same amount of fluid instilled.
3. Repeat procedure until stomach contents return clear or until maximum volume has been reached.
4. For administration of Activated Charcoal, follow gastric lavage with Activated Charcoal slurry in 20 to 150 ml boluses.