Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACEP, or UAEM. The editors reserve the right to edit and publish letters as space permits.

CORRESPONDENCE Value of Lidocaine Jelly in Nasotracheal Intubation

To the Editor: The efforts of Dr Iserson to popularize the technique of

blind nasotracheal intubation ]September 1981; 10:468-471, and August 1984;13:601-602] are certainly to be applauded. Emergency physicians should be familiar with this pro- cedure which, although not difficult, does require a certain degree of skill and finesse. Unfortunately there are still some graduates of the "shove it down the nose" school around. 1 I hope the efforts of Dr Iserson and others will alleviate this problem.

What concerns me is Dr Iserson's attempt to dispel what he calls the "myth" that lidocaine can be helpful for nasotracheal intubation. He quotes a University of Utah study 2 that he says "has shown clearly that lidocaine cream [a jelly was used in the study] will abrade the mucosa, es- pecially the vocal cords." This study was small, with only 20 patients per group, and it studied multiple variables si- multaneously. In fact the results seemed to be quite puz- zling to the authors and they quote the results of a previous large, double-blind study of more than 1,000 patients in which the use of topical lidocaine jelly dramatically de- creased the Incidence of postoperative sore throat. 3 The au- thors of the Utah study are left to speculate that perhaps preservatives or carriers such as polyethylene glycol or pro- pylene glycol had some detrimental effect on the mucosa.

One frequent problem with these studies is that the actu- al products used are not specified, so one is uncertain what potentially irritating substances were present. The issue is further confused by the use of the term "cream." Creams, ointments, and jellies have different carriers and thus differ- ent properties. The 2% lidocaine jelly marketed as Xylo- caine by Astra Pharmaceuticals is an aqueous jelly that con- tains carboxymethyl cellulose rather than propylene glycol as a carrier. I know of no studies attributing any irritant properties to this product. This lidocaine jelly has excellent lubricating and anesthetic properties, as evidenced by its widespread usage for urethral procedures.

Often in the setting of urgent nasotracheal Intubation the ideal nasal anesthesia (4% cocaIne solution) is either un- available or too slow in its onset. Aerosolized lidocaine or cetacaine are suitable alternatives and, although they should be, they are not always available or readily located by physicians intubating patients in unfamiliar areas of the hospital.

The 2% lidocaine jelly is a useful adjunct to nasotracheal intubation because it 1) adds no time to the procedure; 2) has suitable lubricating properties; and 3) provides mucosal anesthesia in the first few minutes following intubation, thus facilitating patient tolerance of the tube. If aerosolized agents are not available and time permits preintubation anesthesia, this can be accomplished comfortably by apply- ing the lidocaine jelly to the surface of a loose-fitting nasopharyngeal airway placed in the nose for a few mo- ments prior to the actual intubation.

Nasotracheal" mtubation also can be facilitated by the in- tranasal administration of 1% phenylephrine (Neo-Syn- ephrine) a few minutes prior to intubation. By vasocon-

stricting the nasal mucosa, this has the theoretical ad- vantage of allowing the comfortable passage of a larger diameter tube with minimal hemorrhage. This has been helpful In my experience, but has not been studied.

The widely attested value of lidocaine jelly is not a myth. It serves as a useful adjunct to nasotracheal intubation, both in facilitating passage of the tube and In increasing patient comfort following the procedure. It can be stored conve- niently in a multiuse tube and should be readily available on the intubation tray in the emergency department.

Jeff Mitchell, MD Department of Emergency Medicine St Ann's Hospital Columbus, Ohio 1. Iserson KV: Nasotracheal intubation: Myth vs reality. Ann Emerg Med 1985;14:379. 2. Loeser EA, Stanley TH, Jordan W, et al: Postoperative sore throat: Influence of tracheal tube lubrication versus cuff design. Can Anesth Soc J 1980;27:156-158. 3. Lund LO, Daos FG: Effects on postoperative sore throat of two analgesic agents and lubricants used with endotracheal tubes. Anesthesiology 1965;26:681-683.

In Reply: Dr Mitchell is certainly correct when he describes a jelly

rather than a cream being used in the study cited. Unfortu- nately, just as in my own case, clinicians (both physicians and nurses) are often sloppy in their use of terms referring to topical preparations. In fact, in the United States a number of different topical formulations for lidocaine HC1 are available, including 2.5% and 5% ointment; 3% cream; 2% jelly; and 2%, 4%, and 10% solution. My personal expe- rience, in many institutions, has shown that frequently a preparation other than the jelly (often the ointment) is on the intubation cart for use. I don't believe Dr Mitchell or anyone else would question the fact that the ointment is significantly more abrading than the jelly.

However, two points that Dr Mitchell raises are in need of expansion and clarification. He notes that although the jelly probably does have suitable lubricating properties, it doesn't actually provide anesthesia for at least the first few minutes after the intubation has been completed. In the pa- tients whom I have intubated, anesthesia most often is needed during intubation, rather than following it. Anesthe- sia could, however, be achieved by using aerosolized agents prior to intubation.

I find it hard to believe that any critical care area would not have an aerosolized anesthetic readily available and easily located for use In intubations.

The bottom line then is that Dr Mitchell and I agree on the following points: 1) adequate anesthesia that can be achieved with aerosolized agents prior to intubation is useful; 2) adequate lubrication is necessary and can be

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CORRESPONDENCE

achieved with any water-soluble jelly (including 2% lido- caine HC1); and 3) lidocaine jelly does not provide anesthe- sia during intubation when merely applied to the endo- tracheal tube, which is the most commonly used technique.

Kenneth V Iserson, MD, FACEP Section of Emergency Medicine University of Arizona Health Sciences Center Tucson, Arizona

Gastric Emptying and Activated Charcoal

To the Editor: I read with interest "Management of Acutely Poisoned

Patients Without Gastric Emptying" by Kulig and cowork- ers [June 1985;14:562-567]. As opposed to previous studies comparing differences in drug absorption after various re- moval procedures, this study addressed the pertinent issue of "clinical outcome." Although no difference was shown in clinical outcome of patients lavaged more than one hour post ingestion as compared to patients treated with acti- vated charcoal alone, one cannot conclude that activated charcoal improved the clinical outcome of either group studied. Without a control group we can only conclude that neither method would improve clinical outcome in relation to the. other.

At present, it would seem prudent to continue gastric emptying in combinat ion with activated charcoal for the following reasons: 1) no study has refuted the concept that drags with an anticholinergic component may delay gastric emptying; 2) bezoar formation, which may occur after the ingestion of a large quantity of certain drugs, may result in prolonged absorption of drug or delayed gastric emptying; 3) no study has proven activated charcoal alone is more effective than gastric emptying in reducing the absorption of large quantities of drug commonly seen in an intentional overdose; and 4) gastric emptying has a very low incidence of adverse effects when done properly.

Until these issues are addressed, gastric emptying in com- bination with activated charcoal and cathartics should be considered the "standard of care."

Gary W Everson, PharmD Clinical Toxicology Fellow Children's Hospital of Pittsburgh Pittsburgh, Pennsylvania

In Reply: We thank Dr Everson for his thoughtful comments on our

research. We agree, and stated so in our article, that it is possible that the administration of activated charcoal did not affect the clinical outcome in any patient group. We did not include an "observation only" control in our study be- cause the H u m a n Research Commi t t ee of our hospital would not have approved the inclusion of such a group.

Dr Everson's other comments appear to be based on the philosophy that gastric emptying procedures should be in- cluded in the "standard of care" until they can be proven ineffective or unsafe. This philosophy should be contrasted with scientific and ethical standards in this country that mandate that before a drug, chemical, or device is allowed to be used on human patients, it must first be shown to be

effective and safe. Does evidence really exist tha t gastric emptying pro-

cedures can remove bezoars, or that they result in a low incidence of adverse effects, as Dr Everson implies? Are gas- tric emptying procedures more effective in patients who have overdosed on anticholinergic drugs? We have not been able to find evidence in the literature that would indicate that these statements are tree.

Our study is only one example of an accumulating body of new data that concludes that gastric emptying procedures are frequently ineffective 1-4 and may themselves result in morbidity s-8 and mortality.9, lo We maintain that the "stan- dard of care" for management of acute poisoning in the emergency depar tment mus t be based on scientific re- search, and not on speculation about the theoretical bene- fits of induced emesis or lavage.

Kenneth Kulig, MD, Associate Director Rocky Mountain Poison Center Denver, Colorado

1. Neuvonen PJ, Variainen M, Tokola O: Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur J Clin Pharmacol 1983;24:557-562.

2. Curtis RA, Barone J, Giacona N: Efficacy of ipecac and acti- vated charcoal/cathartic: Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984;144:48-52.

3. Neuvonen PJ, Olkkola KT: Activated charcoal and syrup of ipecac in prevention of cimetidine and pindolol absorption in man after administration of metoclopramide as an antiemetic agent. Clin Toxicol 1984;22:103-114.

4. Moran DM, Crouch DJ, Finkle BS: Absorption of ipecac al- kaloids in emergency patients. Ann Emerg Med 1984;13:1100- 1102.

5. Tandberg D, Liechty EJ, Fishbein D: Mallory-Weiss Syndrome: An unusual complication of ipecac-induced emesis. Ann Emerg Med 1981;10:521-523.

6. Arkenasi R, Abramowicz M, Jeanmart J, et al: Esophageal per- foration: An unusual complication of gastric lavage (letter). Ann Emerg Med 1984; 13:146. 7. Wolowodiuk LJ, McMieken DB, O'Brien P: Pneumomediasti- num and retropneumoperitoneum: An unusual complication of syrup-of-ipecac-induced emesis. Ann Emerg Med 1984;13: 1148-1151. 8. Justiniani F, Hippalgaonkar R, Martinez L: Charcoal-contain- ing empyema complicating treatment for overdose. Chest 1985; 84:404-405.

9. Klein-Schwartz W Gorman RL, Oderda GM, et al: Ipecac use in the elderly: The unanswered question. Ann Emerg Med 1984; 13:1152-1154.

10. Robertson WO: Syrup of ipecac associated fatality: A case re- port. Vet Hum Toxicol 1979;87-89.

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