Sux and masseter muscle rigidity

[europeman]

If you give succs and the patient has a malignant hyperthermia reaction including masseter muscle rigidity..... Besides surgical airway, what do u do? I mean dantrolene fine.... But what do u do to open the mouth and proceed with airway control. Roc?

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[Groove]

Eh..?

Anyway, here you go:

1) Trismus/masseter muscle spasm occurs after SCh administration in 0.001 to 0.1 percent of patients.

PubMed

PubMed

Old studies on pediatric patients... I've personally never experienced it.

2 )The disorder is estimated to occur in 0.0004 to 0.00625 percent of patients who receive SCh.

Miller R. Miller's Anesthesia, 6th, Elsevier Churchill Livingstone, Philadelphia 2005.

Rec's seem to indicate dantrolene 1-2mg/kg and full dose of non depolarizing agent with preparation for emergent cric if you are unable to ventilate. I "guess" I would prob shove a couple of nasal trumpets, give a dose of roc, bag, prepare to percutaneous jet ventilate perhaps? I just doubt I'd have to jump straight to a cric in that situation which would be incredibly rare. I would imagine that an emergent cric 2/2 masseter spasm would be one of the rarest and exotic of all airway complications but theoretically plausible. Though that seems to be the kind of theoretically plausibility that Rosie Huntington-Whiteley will conceive my love child by the end of the year.

Btw, I would love the above complication risk odds on ALL my procedures.




Psst...That question will not be on any of your inservice or board exams.

 

[namethatsmell]

Nasotracheal intubation.

 

[diphenyl]

Give pavulon

 

[Rendar5]

Hard to nasally incubate someone not spontaneously breathing I would think

 

[namethatsmell]

Hard to nasally incubate someone not spontaneously breathing I would think

No doubt. But it worked for a pt with this in our shop.

 

[diphenyl]

Although no higher chance of success than any other blind intubation at that point. ^^^

 

[namethatsmell]

Although no higher chance of success than any other blind intubation at that point. ^^^

Maybe I should have clarified--pt at our shop got a nasal tube via a fiberoptic scope.

 

[diphenyl]

^^ I stand corrected.

 

[Groove]

It would take me 10-15 mins to get a bronch brought down to the ED, set up and ready to go. The only time I have them ready is if I anticipate needing them prior to intubation i.e. angioedema. I would think most don't have a bronch readily available at hand in most EDs outside residency. Do you guys have them? I've been trying to talk them into buying one specifically for the ED but no luck so far.

 

[Arcan57]

One of the shops I moonlit at had a intubating NP scope hanging on the wall in the "trauma" room. Currently, the fiberoptic option is a peds bronchoscope that's rounded up from the OR.

 

[WilcoWorld]

Yet another reason why Roc is my go-to paralytic.

 

[diphenyl]

I work in a community ED. We have a fiberoptic in our difficult airway cart, however to get it up and going/ assembled is at least 10-15 min's. Unfortunately, none of the RT's know how to set it up, so I would have to do it myself. They also, unfortunately, for the longest time didn't know how to troubleshoot a video McGrath. Now I make it a personal point to know where everything is myself and how to troubleshoot them, so when it hits the fan, it won't matter if the tech is seasoned or not.

 

[TheBlueBlazer]

For whatever reason, call it a unique pt population, I've seen this 3 times already in residency. Maybe it goes along with why we have so much angioedema, and why out patients love codeine so much. Responded to non-depolarizing paralytics each time, and was able to bag them through it

 

[WilcoWorld]

For whatever reason, call it a unique pt population, I've seen this 3 times already in residency. Maybe it goes along with why we have so much angioedema, and why out patients love codeine so much. Responded to non-depolarizing paralytics each time, and was able to bag them through it

So why don't you make non-depolarizing agents your 1st line, or have you already?

 

[Old_Mil]

Speaking of broncos copes in the ED, I had the chance to play around with an Ambu A-scope at an airway course. Have any of you had the chance to use it in real life?

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[deleted171991]

If you give succs and the patient has a malignant hyperthermia reaction including masseter muscle rigidity..... Besides surgical airway, what do u do? I mean dantrolene fine.... But what do u do to open the mouth and proceed with airway control. Roc?

You mask ventilate, maybe put in a nasal airway. If you can't ventilate, emergency surgical airway. Roc might work, too (I would go with high dose, 1.2mg/kg).

Masseter spasm after sux is extremely rare (still have to see one after 5 years). Most of the time, it's not from sux, it's from insufficient induction agent.

 

[anes]

The previous teaching was that the incidence of MH after sux induced MMR was up to 50%. This is most likely due to the very rare occurrence of either of these events. The true incidence of MH after MMR is likely much much lower.

If you get MMR after sux it doesn't hurt to try roc (unless of course the reason for sux was anticipated difficult airway).
However, if the MMR breaks from ROC, it was very very very unlikely that it was MH. You can probably drop MH off of your differential and avoid the dantrolene. MH reaction occurs at the level of the muscle (distal to the neuromuscular junction) and in a true MH scenario roc should do nothing.