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AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 6 n November

1992

of National Health and Welfare, Health Protection Branch, for their consideration. Readers are urged to examine wall outlets in their institution and to institute appropriate educational and awareness programs. The author thanks Viola Norwood aration of this report.

for her assistance

ISSER DUBINSKY.

in the prep-

BSc, MD

North York General Hospital University of Toronto Toronto. Onturio. Canudu

References

FIGURE 1. cle.

Photo of wall outlet for medical gases in patient cubi-

treated with salbutamol and ipatropium bromide by mask. nitroglycerine paste, and diltiazem. as well as her other regular medications. Despite therapy, she continued to complain of shortness of breath. Orders were given to place her on a venturi mask with an FIO, of 30% and medical consultation requested. Admission was ordered. but owing to the unavailability of an inpatient bed, the patient was kept in the emergency department overnight in the examining cubicle in which she initially had been examined and treated. Therapy continued overnight, but the patient continued to complain of dyspnea and orthopnea. Her Fro2 was adjusted on the venturi mask to 35% and subsequently, to 40%. Despite this, the patient continued to complain of shortness of breath and was treated with morphine and ativan on one occasion. Repeat arterial blood gas determinations done after the Ftoz was increased to 35% and again to 40% showed essentially no change from the initial determination. After the third blood gas result returned, the suspicion of a defect in the gas delivery system arose. Careful scrutiny revealed that the oxygen tubing was indeed attached to the medical air outlet. not the oxygen source. The oxygen tubing was subsequently attached to the appropriate flowmeter and the patient’s symptoms improved. Repeat arterial blood gas determinations done on oxygen showed improvement in PO,. The subsequent course in the hospital was uneventful. This patient was one of the first treated in a newly renovated department. An integral part of the renovation/addition project was the installation of new oxygen, suction, and medical air lines and systems. It was quickly recognized that although the oxygen and medical air systems were labeled, the flowmeters were indistinguishable, and that the oxygen tubing readily tit onto either outlet (Figure 1). This concern was rapidly confirmed by our unfortunate experience with one of the first patients treated in the new facility. Inquiries were launched into the availability of “color-coded” flowmeters to avoid such errors in the future. Unfortunately. none are currently available. As a consequence of this experience. all the air flowmeters in our department have been removed and are reconnected on a patient-specific basis only. Other specialties (eg, anesthesia) already have recognized the potential of inappropriate hook-up to gas delivery systems and have responded with systems of pin indexing and color coding of tanks and delivery lines (eg, oxygen, white; nitrous oxide, blue; air, grey and black stripes). While complications in this patient were fortunately minimal, there is a clear potential for catastrophe. Alternatives to avoid such disaster include color coding of flowmeters to universal standards (eg, white for oxygen, grey-black stripes for medical air), colortreated gas tubing. or the creation of “gas-specific” connectors that link tubing to flowmeters. In the interim, this report has been forwarded to the Department

1. Pilot tube’s resemblance to feeding tube connector cause of near fatal accident. Biomed Saf Stand 1987;1:51

is

2. Katz L, Crosby JW: Accidental misconnections to endotracheal and tracheostemy tubes. Can Med Assoc J 1986;135:1149-1151 3. Hazards of Medical Device Connectors (Medical Devices Alert). Ottawa, Canada, Health Protection Branch, Department of National Health and Welfare, July 1987, pp 13-15 4. Dubinsky I: Near death caused by accidental misconnection to an endotracheal tube. Can Med Assoc J 1987:137:1105-l 106

AVOIOING NEEDLE-STICK INJURIES IN THE EMERGENCY DEPARTMENT To the Editor:-In the ongoing effort to avoid needle-stick injuries in the emergency department. Dr Renschler’ recommended one solution to the problem. He suggests installing disposable needle containers on all gurneys. mounted right underneath the patient on both sides and at the head of the gurney. Unfortunately. this suggestion has a major drawback with both medical and medicolegal implications. We have had the unfortunate experience of children. both our patients and their offspring, playing with needle boxes within their reach. In one case a child put her hand into a needle box and was stuck with a contaminated needle even though the container was designed to prevent such an occurrance. We have since heard of other emergency departments being cited for having needle disposal containers within a child’s reach. Having these containers conveniently placed near the bedside is an important health care and preventive health measure. Nevertheless, mounting disposal containers on all gurneys can be dangerous unless they are mounted clearly beyond the reach of children. HOWARD A. FREED,

MD

Albany Medicul College Albany. NY

Reference 1. Renschler MF: Avoiding needle-stick injuries in the emergency department. Am J Emerg Med 1992;10:267-268 (letter)

A MODIFIED METHOD TO INSERT A NASOGASTRIC TUBE WITHOUT KINKING IN THE NASAL CAVITY To the Editor:-The nasogastric (NG) tube is commonly used in many situations such as upper gastrointestinal bleeding, head injury, and some operative procedures. Insertion of the NG tube is quite easy in the majority of patients, but there is some difficulty in inserting the NC tube when the patient is unconscious or anesthetized without swallowing capability because it often kinks in the oropharynx or nasopharynx. If the NG tube passes through the nasal cavity into the oropharynx in the unconscious patient, the medical staff. using fingers or instruments, can guide the NG into the esophagus without kinking in the oral cavity.

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CORRESPONDENCE

FIGURE 3. Longitudinal incision along the nasotracheal tube with the protection of the nasogastric tube.

FIGURE 1. Precurved nasotracheal tube is intubated through nasopharynx, then nasogastric tube is inserted along the nasotracheal tube. But if the NC tube cannot pass through the nasal cavity, the NC tube is inaccessible. In such circumstances, a larger size of NC tube should be tried, because the larger size of the NC tube is more rigid. Occasionally, however, even the larger size of the NC tube (eg. French no. 16) cannot pass through the nasal cavity due to some resistance which makes the NC tube kink in the nasal cavity. Then a modified method is needed to resolve the condition. Firstly, a lubricated nasotracheal tube is inserted into the nostril and pushed through the nasal cavity. This movement should be gentle, carefully guiding along the designed curve of the nasotracheal tube. The precurved nasotracheal tube is usually rigid enough

to pass through the nasal cavity without kinking in the nasopharynx. Next, an NC tube of smaller diameter than the nasotracheal tube, lubricated with jelly, passes along the inner lumen of the nasotracheal tube (Figure 1). After the NC tube passes out the end of the nasotracheal tube, the tip of the NC tube is held with fingers or instruments through the oral cavity and the nasotracheal tube is withdrawn slowly and carefully (Figure 2). Finally, the NC tube can be easily pushed into the esophagus using instruments or fingers. Then the withdrawn nasotracheal tube is removed by making a longitudinal incision along the nasotracheal tube (Figure 3). This method is an alternative way to insert an NC tube when difficulty in intubation of the NC tube occurs. We use the precurved and more rigid character of the nasotracheal tube to pass more easily through the nasopharynx and guide the NC tube. The method can prevent the intracranial complication of NC intubation,‘-3 because the precurved nasotracheal tube would guarantee the NC tube would not trespass into the intracranial space. Although a precurved silastic nasopharyngeal airway was suggested to prevent intracranial comp1ication.4 we believe that the nasotracheal tube can serve better than the nasopharyngeal airway. In our experience, the nasopharyngeal airway is too short for some patients, so we develop this method to use the nasotracheal tube instead of a nasopharyngeal airway if the latter is not available or suitable. This method is not suggested for routine NC insertion, because it may cause nasal bleeding and require several instruments. We use this method only when several attempts at NC intubation have been made, the larger size of NC tube has been used for insertion, and the patient is not suited for oral insertion of the NC tube. But the method is not suitable for use in nasal cavity stenosis or obstruction, or in cases of malignancy found in the nasal cavity, due to easy touch-bleeding during intubation. YIH-SHANG CHEN, MD SHIH-MING WANG, MD National Taiwan University Taipei. Taiwan, Republic of China

References 1. Wyler AR, Reynolds AF: An intracranial complication sogastric intubation. J Neurosurg 1977;47:297-298 2. Koch KJ, Becker GJ, Edwards MK: Intracranial of a nasogastric tube. AJNR 1989;10:443-444

FIGURE 2. Nasogastric tube is held and advanced forward, then nasotracheal tube is withdrawn slowly.

of na-

placement

3. Fletcher SA, Henderson LT, Miner ME: The successful surgical removal of intracranial nasogastric tubes. J Trauma 1987;27:948-952

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4. William F: Bouzarth: Intracranial tion. J Trauma 1978;18:818-819

AMERICAN

nasogastric

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1992

reported we recommend that emergency physicians be aware of this potential adverse effect. WILLIAM BRADY, MD KENT HALL, MD

ERYTHROMYCIN-RELATED DYSTONIC REACTION

Medical College of Wisconsin Milwaukee, WI

To the EditorzWe

report the case of a 23-year-old black man who presented to the emergency department with an apparent dystonic reaction related to erythromycin use. At approximately 12:OO noon on the day of presentation, the patient took a single erythromycin tablet belonging to a friend. The erythromycin formulation the patient used was EES-400. erythromycin ethylsuccinate, an ester of erythromycin suitable for oral administration. The patient stated that he took the erythromycin for nasal congestion which he experienced over the last 2-3 days. Approximately 5 hours after use of the erythromycin the patient developed neck pain and muscle spasms with deviation of the head to the right and protruding of his tongue. The patient denied earaches. sore throat. cough, recent trauma, medication use other than that described above. and illegal drug use. The patient stated he had no medical problems, had never been under the care of a psychiatrist, and had not seen a physician for approximately 2-3 years. Physical examination showed a young black male in moderate distress with normal vital signs and a temperature of 97.8”F. The patient was sitting on the examination table with his head twisted to the right and tongue protruding. There was palpable muscle spasms of the muscles of the right neck. Head and neck examination revealed no evidence of an infectious or traumatic process. The remainder of the patient’s physical examination was within normal limits. A serum toxicologic screen was negative. Based on the patient’s history and physical findings, it was felt that the patient was experiencing a dystonic reaction. He was treated with parenteral diphenhydramine with resolution of his symptoms in approximately 2-3 minutes. The patient was observed in the emergency department for an additional 30 minutes when he had recurrence of the above stated symptoms. Physical examination at this time was identical to his initial presentation. The patient was treated again with diphenhydramine as well as benztropine. Once again the patient responded within a 2- to 3-minute period with complete resolution of his symptoms. The patient was observed in the emergency department for an additional 2 hours with no recurrence. He was discharged on oral diphenhydramine 25 mg every 6 hours for the next 3 days. The patient was further encouraged not to use erythromycin in the future and also encouraged not to use medication unless prescribed for him by a physician. We report the case of a patient with an apparent dystonic reaction related to erythromycin use. A review of the English language literature from 1966 to the present yielded no report of extrapyramidal reactions in general or dystonic reactions in particular to erythromycin or macrolide antibiotics. Further review of the Physicians’ Desk Reference and Wisconsin Poison Control yielded similar results. Previously reported adverse reactions to erythromycin most commonly include gastrointestinal upset. Neurologic adverse reaction to erythromycin in the past have included ototoxicity and exacerbation of myasthenia gravis. Most often extrapyramidal reactions (dystonic reaction) are related to neuroleptic medication. A literature search was also performed looking for reported extrapyramidal reactions to ethylsuccinate, the soluable salt formulation of this erythromycin formulation. This literature search was also negative. The possibility of an inflammatory or traumatic torticolis was also considered. However. based on the patient’s history and physical examination no evidence of an infectious, inflammatory, or traumatic etiology could be found. Further, the patient’s complete response to diphenhydramine and benztropine suggests that inflammatory or traumatic etiology was not involved in this case. In summary, we report the case of a dystonic reaction to the ethylsuccinate salt of erythromycin. As no previous cases have been

n Volume

KISS OF LIFE MASK: EVALUATION OR OPINION? To the Editor:-1 am writing in reference to the article by Lightsey et al.’ At first glance I was quite impressed with the level of evaluation of the items tested. But, after more in-depth evaluation of the material, several issues give me cause for concern. In the abstract, the authors admit that they designed the product that the paper is focused on. This fact alone requires that you read anything further with great scrutiny. Next the authors claim that their study is the only such “research” of this time. This also is not true. Cydulka and Connor published an evaluation of all masks on the market at that time. This was published some time prior to the Lightsey article and should have been referenced.” Overall, the “study” is presented in what appears to be a scientific manner, but after close observation it is noted that most of the evaluation of any product is done only on one item. As well, a good portion of the discussion is spent discussing potential negative issues of a competitor’s product upon which the authors have no basis in objective data or fact. This is particularly true when discussing the potential for patient vomitus. Mr Lightsey. states, regarding the C.P.R. Microshield. (Medical Devices International, Gurree, IL), “Furthermore, vomiting would dislodge the mask and potentially contaminate the rescuer.” I would hope that any rescuer would remove any mask/shield device to clear the airway after emesis as recommended by the American Heart Association.3 On the contrary the Kiss of Life (KOL) may be a potential danger as the earstraps may not allow free flow of vomit from the patient’s mouth, therefore significantly increasing the likelihood of aspiration if the rescuer is not alert to the situation. In fact the authors state, “it is selfretaining and is not easily displaced.” In addition, the authors failed to perform the human immunodeticiency virus culture. the Xenon flow study or the anesthetized spirographic evaluation on any of the mentioned-products except for the KOL, once again leaving the authors with no scientific basis for the statement that the C.P.R. Microshield “carries a potential risk for oropharyngeal trauma when inserted over the tongue.” Why is it that the KOL, which incorporates “a one-way valve. which lies over the tongue of the victim is protected by an overlying bite block”. is any less likely to induce oropharyngeal trauma? The authors ask us to believe their product is superior because a trained anesthesiologist was able to place the KOL in 10 volunteer patients. This is not proof enough for me. Therefore. one must view the entire paper as more of an opinion than a scientific and objective evaluation of resuscitative mask/ barriers. MARK D. WESTFALL, DO

Evanston Hospital Evanston, IL

References 1. Lightsey DM, Shah PK, Forrester JS, et al : A human immunodeficiency virus-resistant airway for cardiopulmonary resuscitation. Am J Emerg Med 1992;10:73-77 2. Cydulka RK, Connor PJ, Myers TF, et al: Prevention of oral, bacterial flora transmission by using mouth-to-mouth ventilation during CPR. J Emerg Med 1991;9:317-321 3. Montgomery WH (ed): Student Manual for Basic Life Support, Cardiopulmonary Resuscitation. Chicago, IL, American Heart Association, 1981, p 49

Editor’s note: The authors did not respond to the above letter.

A modified method to insert a nasogastric tube without kinking in the nasal cavity.

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