Nasogastric tube placement

Indications

1. Aspiration of stomach contents (poor sens and spec for UGI bleed)
2. Vomiting likely to be dangerous or recurrent
   1. Bowel obstruction
   2. Paralytic ileus
   3. Acute gastric dilatation
3. Stomach decompression prior to surgery or peritoneal lavage

Contraindications

1. Facial fx involving cribriform plate

Relative Contraindications

1. Severe Coagulopathy
2. Gastric bypass and lap band procedures
3. Esophageal strictures/hx of alkali ingestion

Equipment Needed

1. PPE including gown for practitioner and pt
2. NG Tube- typically a 16F or 18F Sump
3. Syringe/Bulb- 50-60cc
4. Tape
5. Emesis basin
6. Towels
7. Cup of water with straw

Procedure

1. Inform pt of R/B/A
2. Position pt upright
3. Place towel over pt's gown and emesis basin in pt's lap
4. Estimate length of insertion
   1. Measure from tip of nose to earlobe to xyphoid and then add 15cm.
5. Check nares for obstruction and pass through the most widely patent nare
6. Provide relief from discomfort
   1. Topical vasoconstrictors to both nares
      1. Oxymetazoline or phenylephrine
   2. Topical Anesthetics (5 min prior to procedure)
      1. Benzocaine, tetracaine, nebulized lidocaine (4 or 10%), lidocaine jelly
      2. Anesthetize OP, as well, to prevent gagging
   3. Antiemetics
      1. Zofran and reglan 15 min prior may reduce gagging and nausea
7. Insert tube along floor of nose under inferior turbinate
8. Pause when NGT is in OP
9. Flex the pt's neck to decrease chance of tracheal passage
10. Advance into esophagus
    1. Having the pt sip water may aid in esphageal passage
    2. Withdraw to OP promptly if excessive coughing, gagging, choking or voice change
11. Once NGT is in esophagus, rapidly insert rest of tube to premeasured length
12. Confirm placement
    1. Insufflate air while listening over stomach
    2. Obtain radiograph
    3. Check pH of aspirate (pH<4 there is a 95% chance the aspirate is gastric)
13. Secure to patients nose with tape
14. Attach to desired suction, not to exceed 120 mmHg

Complications

1. Pulmonary placement
2. Intracranial placement
3. Increased cervical and cranial pressures with gagging/vomiting
4. Epistaxis
5. Invagination of stomach lumen into eyes of ngt

Source

1. Roberts: Clinical Procedures in EM, 5th ed