Trismus

[mycrofft]

Good to know you're all right.

 

[sleepless near seattle]

Good to know you're all right.

Thanks and thanks as well for the further insight in the pm's.

 

[jwk]

Wow, what a call, it has had me researching for the past hour or so, and something I'm going to bring up to my fellow medics and Docs.

My first thought was Tricyclic Antidepressant Toxicity, or some kind of OD. But the Trismus brought me there, not common, but that is where my mind went.

As i was reading your account, I agreed that the Succs should have been withheld due to the BP, and I would have tried a Nasal Tube, or surgical cric. if anything just to make sure I had a secured airway. Also, when the PT coded, I would have started going down that road with CPR and Epi. If anything, just to cover my butt.

If I were in your shoes during that call, I'm not sure I would have done anything differently, but sitting on my couch it is easy for me to run it.

You did what you could, when you could, that is all we can do.

You mean the propofol should have been withheld? There is no contraindication to sux simply because of hypotension.

The only thing that came to my mind would be neuroleptic malignant syndrome. It has a similar presentation to malignant hyperthermia (a rare but devastating anesthesia-related syndrome) - that's the only reason I'm even aware of it. I think you had bigger issues than this with the GI bleed.

On the truly rare instances where sux "doesn't work", use a nondepolarizer such as roc or vec.

*************

from Medscape...

The neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Although potent neuroleptics (eg, haloperidol, fluphenazine) are more frequently associated with NMS, all antipsychotic agents, typical or atypical, may precipitate the syndrome.

 

[mycrofft]

Thanks JWK!

You answered a three year old riddle for me about a pt I posted on. Malignant neuroleptic syndrome...got it.

 

[Melclin]

Someone may have mentioned this already but how about dodgy sux?

Its temp sensitive or maybe you just had a bad batch.


Also, nice work on taking constructive criticism well. Its so frustrating that people post scenarios with a question but refuse to accept answers they don't like.

 

[triemal04]

Someone may have mentioned this already but how about dodgy sux?

Its temp sensitive or maybe you just had a bad batch.


Also, nice work on taking constructive criticism well. Its so frustrating that people post scenarios with a question but refuse to accept answers they don't like.

I just got done looking that up as it was the first thing that popped into my head. I've always wasted uncooled sux after 2 weeks to a month. Now granted there'll be more fluctuations in temp in an ambulance, but this was surprising to see: http://www.ncbi.nlm.nih.gov/pubmed/6702837

I still think something along those lines (sux failure) was the root cause; have to ask why (if you have it) a different paralytic wasn't used after the first dose of sux failed, AND if paralytics were pushed by the ER doc before their intubation attempt; your narrative makes it sound like they weren't.

 

[mycrofft]

How comfortable would one be to stack another paralytic on top of a possibly defective paralytic? Or even a confirmed defective paralytic? Sounds like a question for an anesthesiologist.

 

[triemal04]

How comfortable would one be to stack another paralytic on top of a possibly defective paralytic? Or even a confirmed defective paralytic? Sounds like a question for an anesthesiologist.

Why wouldn't it be? It's done pretty regularly actually: pt intubated using a short-acting paralytic and sedatives, then quickly given a long acting paralytic and more sedatives (we'll ignore whether or not the long acting paralytic is actually needed for now). Looks like a routine RSI protocol to me...

In the given case, you have a patient who's condition is unchanged after a depolarizing paralytic that loses efficacy when held at room temperature is given. (granted it would appear that it doesn't lose that much...maybe) First thing that pops into my head is the simplest solution: it didn't work because it's no longer good/expired. Move on to a paralytic that works slightly differently and isn't.

edit: routine EMS RSI protocol...I've seen much, much, much less sux used in ER's and OR's than just using rocuronium or vecuronium.

 

[jwk]

Why wouldn't it be? It's done pretty regularly actually: pt intubated using a short-acting paralytic and sedatives, then quickly given a long acting paralytic and more sedatives (we'll ignore whether or not the long acting paralytic is actually needed for now). Looks like a routine RSI protocol to me...

In the given case, you have a patient who's condition is unchanged after a depolarizing paralytic that loses efficacy when held at room temperature is given. (granted it would appear that it doesn't lose that much...maybe) First thing that pops into my head is the simplest solution: it didn't work because it's no longer good/expired. Move on to a paralytic that works slightly differently and isn't.

edit: routine EMS RSI protocol...I've seen much, much, much less sux used in ER's and OR's than just using rocuronium or vecuronium.

Unless you've had the sux out for quite a while, I would expect it to work, and especially with a 2nd dose. It's not like it just suddenly stops working at X number of weeks after taking it out of cool storage. It loses potency slowly. There's no telling how long our pre-filled sux syringes stay on our anesthesia carts. They're stored at room temp for long periods of time and would only be tossed if they pass the manufacturer's expiration date on the label. I have far more problems with lousy roc than I ever have issues with sux.

 

[18G]

A very interesting case.

Just speaking for myself I would have definitely attempted a nasotracheal intubation. And if unsuccessful, I would have went to a surgical airway. The patient was at the point of intervene now or die. I think this is a classic case of airway first. No airway and patient dies.

Rarely do we do surgical airways (I've never done one in the field, only on a cadaver) but in a patient with trismus and an emesis filled airway, this is the only and best option to go with outside of the naso intubation attempt. If there is ever a case to do a surgical airway this one was it.

I get the heat of the moment, pushing propofol with the hypotension and am sure going forward you will remember. The hypoxia caused the bradycardia so I would not have considered atropine since we already know why the patient is brady. Why waste time giving a drug when we already know what we need to do to increase heart rate which is airway.

It's easy after the fact to say what should have been done. That was one heck of a call to manage.

 

[Christopher]

Hopefully roc will continue catching on and we'll put sux to bed as an RSI drug.

 

[usalsfyre]

Hopefully roc will continue catching on and we'll put sux to bed as an RSI drug.

As long as the misguided notion about short duration safety persist it's unlikely.

 

[Christopher]

As long as the misguided notion about short duration safety persist it's unlikely.

It's my favorite myth in medicine at the moment...

...that the paralytic wearing off for an RSI drug is somehow a helpful thing if you can't tube the patient.

Because they were soooo well off when you started that they'll be just peachy once the sux wears off. No. Big. Deal.

Champions of succinylcholine's "short duration" are scary airway people.

 

[sleepless near seattle]

Someone may have mentioned this already but how about dodgy sux?

Its temp sensitive or maybe you just had a bad batch.


Also, nice work on taking constructive criticism well. Its so frustrating that people post scenarios with a question but refuse to accept answers they don't like.

We do store our sux at room temp on the rig and only dispose it at the expiration date, I know this is a questionable practice. It's been the practice for many years, well before I came to the system. It's been asked and answered through 3 different MPDs over at least 15 years that I know of as well as a variety of anesthesiologists, they all agree with jwk (sounds like he/she might be an anesthesiologist). To my knowledge, this is the first case of it not working in our county (at least in the ten years I've been around). That doesn't mean it's not possible though. The articles and documentation about it needing to be kept cool came from somewhere after all. As for the constructive criticism, thanks for the compliment. I figure why post a case with questions if you aren't willing to accept answers although I have seen some pretty judgmental and negative stuff on here as well (thankfully not in this thread).

For the others who've suggested/asked about non-depolarizing, yes we carry vec and/or panc if vec's not available. It's a good question, I guess I just went with the sux again since that's what Med control said to do. Having had this experience combined with all the feedback, I'm confident that I will do things a bit differently in the future. While I do believe securing the airway was key here and I wish I would have accomplished it, I still believe it would have changed the pt's outcome. I'll share the autopsy results when I hear. It should shed some light. Thanks everyone for making this experience on EMT life a positive one.

 

[jwk]

It's my favorite myth in medicine at the moment...

...that the paralytic wearing off for an RSI drug is somehow a helpful thing if you can't tube the patient.

Because they were soooo well off when you started that they'll be just peachy once the sux wears off. No. Big. Deal.

Champions of succinylcholine's "short duration" are scary airway people.

Ah, spoken by someone who uses sux how often?

Sux has it's place, whether you realize it or not. If it didn't, it would disappear from anesthesia carts around the world, which it has not. It is still the RSI NMB drug of choice for many of us in anesthesia, myself included. One of the most intense areas of NMB drug research is to find a non-depolarizing drug that works as fast as, and wears off as fast as sux. Nobody has found it yet.

 

[Aidey]

For elective/non-emergent surgery letting the sux wear off is a legitimate option. It is a crappy excuse in emergency airway management.

 

[coolidge]

any value of placing two nasal airways

Any value of placing two nasal airways and bagging?

 

[NomadicMedic]

Any value of placing two nasal airways and bagging?

The OP mentioned "copious amounts of puke" when bagged with an NPA.

I might have moved on down to a surgical airway...especially after reading how difficult the intubation was. But I wasn't there

 

[Christopher]

Ah, spoken by someone who uses sux how often?

Sux has it's place, whether you realize it or not. If it didn't, it would disappear from anesthesia carts around the world, which it has not. It is still the RSI NMB drug of choice for many of us in anesthesia, myself included. One of the most intense areas of NMB drug research is to find a non-depolarizing drug that works as fast as, and wears off as fast as sux. Nobody has found it yet.

I'll give you that EMS RSI is rare (might make 4/yr) compared to anesthesia. If mine were elective I'd be Ok with sux. The profile of roc is so much more attractive in the emergent airway.

My point is that if I'm Ok with my paralytic wearing off...I probably don't need to be paralyzing that patient.

 

[mycrofft]

If the pt is getting inflations down into the chest without an airway and you place a surgical airway and then resuscitate, won't it blow out the oro-nasopharynx instead of inflating the pt's lungs?