instituted. The comments regarding
`hypothermia are appreciated and
`thought to be addressed on page 2931
`in the section that deals with hypother(cid:173)
`mia.
`Dr Koufman is appropriately con(cid:173)
`cerned with complications of long-term
`endotracheal intubation. The tube sizes
`recommended have been reduced when
`compared with the previous standards
`but are larger t han he would like in
`order to permit suctioning and appro(cid:173)
`priate ventilat ion during the acute
`phases of cardiac arrest and resuscita(cid:173)
`tion. It is hoped that the victim will be
`immediately resuscitated, extubated,
`and therefore not subjected to the
`complications of prolonged intubation
`to which Dr Koufman eludes. These
`sizes of tubes are routinely used during
`anesthesia and, as long as they are Z 79
`implant-tested tubes, and not reused,
`there should be no problem with
`stenosis.
`
`William H. Montgomery, MD
`Straub Clinic and Hospital
`Honolulu
`I. <:ORRF.CTION. JAMA !986;256:172'7.
`2. Standards and l(llidelines for cardiopulmonary resusti•
`talion (CPR) a nd emergency cardiac care (ECC). JAMA
`1980".l44:453·509.
`
`To the Ediwr.-In reading the "Stan(cid:173)
`dards and Guidelines for Cardiopulmo(cid:173)
`nary Resuscitation (CPR) and Emer(cid:173)
`gency Cardiac Care (ECC),"1 I have
`found two points that were particularly
`disturbing and would like to bring
`them to your attention.
`In the guidelines it discusses cough
`CPR and states that "self-induced CPR
`is possible; however, its applications
`are limited to clinical situations in
`which the patient has a cardiac moni(cid:173)
`tor." I feel this statement seriously
`limits the lifesaving potential of this
`technique. As the quality assurance
`director of the Northeast Georgia Med(cid:173)
`ical Services Council and instructor in
`our training programs for advanced
`emergency
`medical
`technicians
`(EMTs),
`I am aware of several
`instances wherein cough CPR was
`effective in maintaining consciousness
`in arrested patients in their homes
`while EMTs were responding to the
`call. None had cardiac monitoring
`being performed at the time. In these
`instances the EMT answering the call
`for help (where an oncoming heart
`attack was suspected) instructed the
`caller to have the victim begin cough(cid:173)
`ing forcefully and persistently if the
`victim began sensing a loss of con(cid:173)
`sciousness. Upon arrival of the EMTs
`and the beginning of electrocardio(cid:173)
`graphic monitoring the victims were in
`ventricular fibrillation yet were con(cid:173)
`scious.
`The second point I found disturbing
`
`JAMA, Oct 3. 1986- Vol 256, No. 13
`
`is concerned with the section on the
`management of obstruction of the air(cid:173)
`ways by foreign bodies. The guidelines
`failed to mention the use of gravity as
`a helpful aid in
`the dislodging of
`airway foreign bodies, particularly in
`infants and small children. From per(cid:173)
`sonal experience and that of EM.Ts in
`our region, I have become convinced
`that taking the advantage of the use of
`the force of gravity can be an impor(cid:173)
`tant adjunct in the dislodging of for(cid:173)
`eign objects. Tipping a small child into
`a 45° Trendelenburg position or even
`further and continuing the Heimlich
`maneuver or chest blows has been
`effective in dislodging foreign bodies
`when these maneuvers were not effec(cid:173)
`tive with the victim upright or supine.
`Inverting dogs and cats with airway
`foreign bodies has also been effecti ve in
`expelling the objects when success was
`not observed in an upright position or
`horizontal recumbency.
`Dennis T. Crowe, DVM, DACVS
`The U nivcrsity of Georgia
`College of Veterinary Medicine
`Athens
`1. Standards and guidelines for cardiopulmonary re$uscl(cid:173)
`talion (CPR) and emergency cardiac care (ECC). JA MA
`I 986;255:2905-2984.
`
`'Hello? Hello? . .. He Doesn't
`Seem to Answer'
`To the Editor.- In reference to the
`cover of the J une 6 issue,1 you describe
`'1a paramedic] who is holding two
`defibrillation paddles." If this is in fact
`the case, the paramedic is about to
`defibrillate his right ear- not a safe
`practice. However, if you look more
`closely, you will see that the paramedic
`is in fact holding a telephone.
`Stephen R. Gorfine, MD
`New York
`
`I. JAMA 1986;255:284:J.
`
`Acute lschemic Retinopathy due
`to Gentamlcln Injection
`To the Editor. - We recently reviewed a
`number of cases in which gentamicin
`was inadvertently injected into an eye
`and caused blindness. The clinical pic(cid:173)
`ture of acute ischemic gentamicin tox(cid:173)
`icity of the retina and optic nerve is a
`remarkable one (Figure). The entire ret(cid:173)
`ina becomes ischemic and necrotic.1
`1
`·'
`In the cases seen, gentamicin was
`either mistaken for balanced salt solu(cid:173)
`tion, or some other medication, and
`injected into the eye or was injected in
`such a way t hat a high concentration of
`it came in contact with the retina.
`Near the end of intraocular surgery,
`eye surgeons may inject balanced salt
`solution or some other physiological
`solution into the eye in order to regain
`intraocular pressure. In addition, at
`
`Downloaded F.-om: https://jamanetwork.com/ by Andrew Calman on 10/19/2020
`
`Top, Normal retina : fluorescein angiogram, left
`macula. Note normal, patent, branching retinal
`vessels. Vision, 20120. Bottom, Acute occlu·
`sive gentamicin toxicity of the retina: fluorescein
`angiogram, left macula. Note massive nonperfu•
`sion (vascular occlusion) of retina. Remaining
`few vessels leak fluorescein dye. Hemorrhages
`are also present. Vision, perception of light
`only.
`
`the end of certain eye operations, gen(cid:173)
`tamicin is often injected under the
`conjunctiva, prophylactically.• If the
`gentamicin is drawn up early in the
`case and left in an unlabeled syringe, it
`can be mistaken for balanced salt or
`for some other medication and inadver(cid:173)
`tently injected.
`To avoid the problem of inadvertent
`gentamicin
`injection,
`the physician
`should never inject into a patient any(cid:173)
`thing that is not labeled. The only time
`a physician should accept a syringe full
`of medication is when he himself draws
`the medication out of the bottle or sees
`it drawn up, then uses it immediately.
`Nurses should never draw up medica(cid:173)
`tions and leave them unlabeled. If a
`in
`medication must be drawn up
`advance, it should be drawn up into a
`labeled syringe.
`
`Howard Schatz, MD
`IL Richard McDonald, MD
`San Francisco
`1. r.onway Br. r,ampochiaro PA: Macular infarction after
`<•ncfophthalmitis treated with \'itrecwmy and intra\'itreal
`l,!Cntamidn. "fr('}; Ophthalnwl H'86;104::l6i.
`2. McDonald HR. Schatz H. Allen AW, Chenoweth JO:
`Rrt inal toxitity ~ondary to intraocular gentamicin injec~
`tion. Ovl1/lwlmol0tJy, in prt."ss.
`:J. Snider JD. Cohen HB, Chenoweth RG: Acute ischemic
`rNinopathr se<"ondary to intraocular injection of i,centami•
`t in. in Ryan SJ. Dawson AK. Little IIL: J/J.,/im,/ lml,a,.,~
`
`Letlers
`
`1725
`
`Novartis Exhibit 2298.001
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`New York, Grune & Stratton, 1985, pp227-2:l2.
`4. Conway BP, Campochiaro PA: Macular infarction after
`endophthalmitis treated with vitrectomy and intravitreal
`gentamicin. Arch Ophthalmol 1986;104::l67.
`
`Hyperkalemia due to Salt
`Substitutes
`To the Editor.-Near-fatal hyperka(cid:173)
`lemia from potassium supplements and
`salt substitutes continues to be an
`important clinical problem.1,2
`Although its incidence is unknown, it
`seems more likely to occur in azotem(cid:173)
`ic patients, diabetics, or patients
`using drugs
`that affect potassium
`homeostasis (/3-blockers, nonsteroidal
`anti-inflammatory drugs, captopril,
`spironolactone, triamterene, and ami(cid:173)
`loride).3 Salt substitutes may be pre(cid:173)
`scribed to reduce sodium or increase
`potassium intake but are also self(cid:173)
`prescribed by an unknown number of
`patients. We describe a patient who
`experienced near-fatal hyperkalemia
`caused by repeated ingestion of soup
`heavily "seasoned" with a salt substi(cid:173)
`tute.
`Re'f)(m of a Case.-A 70-year-old
`woman was admitted to a local hospi(cid:173)
`tal for transient severe muscle weak(cid:173)
`ness following dinner. She became so
`weak she could not stand and noted
`paresthesias of her hands and mild
`dyspnea. She denied chest pain or
`diaphoresis. On arrival to the emergen(cid:173)
`cy room she was asymptomatic, She
`had known angina pectoris, which was
`well controlled with diltiazem hydro(cid:173)
`chloride, 60 mg four times per day,
`metoprolol, 50 mg four times per day,
`and isosorbide dinitrate, 40 mg four
`times per day. Her blood pressure was
`110/50 mm Hg supine, 98/60 mm Hg
`standing. Her pulse rate was 90 beats
`per minute, and her temperature was
`37°C. The remainder of her physical
`examination results were unremark(cid:173)
`able. Laboratory values were normal
`with the exception of the electrolytes:
`sodium, 145 mEq/L (145 mmol/L);
`chloride, 113 mEq/L (113 mmoVL);
`potassium, 9.1 mEq/L (9.1 mmol/L);
`bicarbonate, 29 mEq/L (29 mmol/L);
`serum urea nitrogen, 23 mg/dL (8,2
`mmol per liter of urea); and creatinine,
`1.2 mg/dL (106 mmol/L), The electro(cid:173)
`cardiogram demonstrated very peaked
`T waves in V2, V3, and V4, a QRS
`interval of 0.08 s, and a PR interval of
`
`Potassium Content of Salt Substitutes
`
`mEq/Teaspoon
`
`Morton's Lite Salt
`Morton's Salt Substitute
`No-Salt
`Nu-Salt
`Adolph's Salt Substitute
`(unseasoned)
`
`38
`72
`64
`67
`
`65
`
`1726
`
`JAMA, Oct 3, 1986-Vol 256, No. 13
`
`0.21 s. A repeated potassium level
`drawn with a large-bore needle and
`syringe without a tourniquet was 7.4
`mEq/L (7.4 mmol/L). The hyperkale(cid:173)
`mia was treated successfully with intra(cid:173)
`venous calcium chloride, bicarbonate,
`and sodium polystyrene sulfonate, Her
`peaked T waves reverted to normal and
`her potassium level at discharge had
`returned to 4.7 mEq/L (4.7 mmol/L).
`The patient denied use of potassium
`supplements but was unaware of the
`potassium content in her salt substi(cid:173)
`tute. She remembered consuming large
`quantities of a homemade soup twice
`on the day of admission. Analysis of
`her soup revealed its potassium con(cid:173)
`centration to be 94 mEq/L (94 mmol/
`L). Subsequent serial serum potassium
`levels measured since she has been an
`outpatient have been normal.
`
`Camment.-A recent trip to a local
`grocery store confirmed that the labels
`of the leading salt substitutes now
`contain warnings about use without
`the advice of a physician. They do not,
`however, warn against use in cooking
`or state a safe maximum daily dose,
`and, in fact, they have the sort of
`wide-bore openings useful for cooking.
`The potassium content per teaspoon
`for several brands is noted in the
`Table.
`Several points should be made con(cid:173)
`cerning this case. (1) Potassium in all
`forms may be overly prescribed by
`physicians and overly consumed by the
`public.4 (2) Severe muscle weakness can
`result from both hypokalemia and
`hyperkalemia.5 (3) A patient could
`present with a cardiac arrest due to
`hyperkalemia associated with an ago(cid:173)
`nal-appearing electrocardiogram and
`the cause could be easily missed.
`Hyperkalemia in our patient was most
`likely due to excessive intake of potas(cid:173)
`sium in the form of a salt substitute.
`(4) Although /3-blockers can clearly
`alter potassium distribution between
`intracellular and extracellular com(cid:173)
`partments, the effect is specific for
`/32-blockers.6 Our patient was using
`metroprolol, a selective /31-blocker. (5)
`It seems
`likely
`that our patient's
`hyperkalemia was adversely affected
`by diltiazem, as suggested by recent
`studies.1·9 Thus,
`calcium blockers
`should probably be added to the list of
`drugs that affect potassium homeo(cid:173)
`stasis.
`The public needs to be more aware of
`the potential danger of salt substitutes.
`Physicians should routinely inquire as
`to their use as they would other drugs
`in the counseling of their patients.
`Robert E. Hoyt, MD
`Kilmarnock, Va
`l. Snyder EL, Dixon T: Abuse of a salt substitute. N Engl
`
`J Med 1975·2·320
`2. McCaugh~n D: Hazards of nonprescription potassium
`supplements. Lancet 1984;1:513-514.
`3. Alvo M, Warnock DG: Hyperkalemia: Medical staff
`conference, University of California, San Francisco. West J
`Med 1984;141:666-671.
`4. Kassirer JP, Harrington JT: Fending off the potassium
`pushers. N Engl J Med 1985;312:785-787.
`5. Adams RD, Victor M: Prineipl,es qf Neurology, ed 3.
`New York, McGraw-Hill International Book Co, 1985.
`6. Ponce PS, Jennings AE, Madias NE, et al: Drug-induced
`hyperkalemia. Medicine 1985;64:357-370.
`7. Johnson IME, McDougall JG, Coghlan TP, et al: Potas•
`sium stimulation of aldosterone secretion
`in vivo
`is
`reversed by nisoldipine, a calcium transport antagonist.
`EndocrinoW(IY 1984;114:1466-1467.
`8. Kelleher S, Gillum D: Increased serum K due to
`combined calcium channel and beta-adrenergic blockade.
`Proc Am Soc Nephrol 1984;17:44A.
`9. Nugent M, Tinker JH: Cardiovascular effects of vera(cid:173)
`pamil during acute hyperkalemia and after calcium thera(cid:173)
`py. Ane.thesiok,gy 1982;57:A3.
`
`Keeping in Trim:
`Nailed Doc Docks Nails
`To the Editor.-Recently, I had an
`elderly patient in the hospital whose
`toenails had been neglected and uncut
`for a long period of time. Because I
`noticed this and because the patient
`asked me to, I requested that the
`nurses take care of this. I was informed
`that nurses no longer cut toenails!
`There is no podiatrist on the hospital
`staff. As an orthopedic consult was
`pending I hoped one of the residents
`would undertake the nail trimming
`when examining her deformed foot.
`Alas! Since the patient chose not to
`have surgery on her foot, the nails
`remained uncut.
`At this stage I accepted the concept
`that in a hospitalized patient, trim(cid:173)
`ming of the toenails is part of primary
`patient care and I borrowed a nail
`trimmer from the nursing staff (who
`were delighted to loan it to me) and
`promptly attended to it, to everyone's
`delight.
`
`Bala V. Manyam, MD
`Southern Illinois University
`School of Medicine
`Springfield
`
`Ethylene Oxide and Cancer
`To. the Ediwr.-In their March 28,
`1986, article, "Epidemiologic Support
`for Ethylene Oxide as a Cancer-Caus(cid:173)
`ing Agent," Hogstedt et a11 assert that
`there is a strong indication that ethyl(cid:173)
`ene oxide is a carcinogen even at
`low-level exposures. The evidence pre(cid:173)
`sented in the article to substantiate
`this claim is very weak and certainly
`lends no credence
`to
`the authors'
`theory.
`The major piece of supporting evi(cid:173)
`dence for this claim appears to be the
`results of the study at plant 3, where
`there was one leukemia death vs 0.16
`expected. The single case of leukemia
`for plant 3 occurred in group C, where
`workers had multiple chemical expo(cid:173)
`sures and the lowest ethylene oxide
`exposures. What does stand out as
`
`Letters
`
`Downloaded From: https://jamanetwork.com/ by Andrew Calman on 10/19/2020
`
`Novartis Exhibit 2298.002
`Regeneron v. Novartis, IPR2021-00816
`
`