Nasogastric tube placement is one of the most uncomfortable procedures in the Emergency Department. Why can’t we find a painless way to do this?

Now that I am doing more fiberoptic nasopharyngoscopes, this issue is coming up more and more frequently. I’ve been using NP scopes mainly to check for laryngeal edema in the setting of angioedema. These recent photos visualize a normal epiglottis and normal laryngeal anatomy, respectively.

Tricks of the trade

Anesthetizing the nasopharyngeal tract

There is no pain-free way to place NG tubes and insert NP-scopes, but this 2-step approach worked amazingly well in my last patient in whom we performed a NP-scope.

Nebulizersm

1. Nebulized lidocaine

I use 4 cc of 4% lidocaine in a nebulizer unit and face mask.

ViscousLidoNosesm

2. Viscous lidocaine

I inject about 5 cc of 2% viscous lidocaine into a nostril.
The patient “snorts in” the lidocaine.

Yes, this 2-step process takes a little more time. If time permits, these extra few minutes are worth it. Just be sure to perform the procedure immediately after the nebulizer treatment is completed. The topical lidocaine wears off quickly.

What techniques do you use?
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD