Case discussion for Residents / peds people...

[somedumbDO]

2 yr old for dental rehab looks syndromic adopted no fhx, first anesthetic had elevated temps was obs for 24 hrs no issues subsequent anesthetics all done at ohs w/ mh avoidance. For the residents what is your plan?


Say you chose im ketamine/midaz/glyco in or. Difficult iv and while attempting 5th iv he/she laryngoscopes spasms can’t break w ppv what would you do?

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[Psai]

If they don't have king denborough, multi mini core or central core i don't give a flying. Gas em down, iv then fiberoptic tube with small amount of prop and fent.

For the second one I would give em the jaw thrust and if nothing then place a tube down with a miller 2.

 

[deleted875186]

Perhaps I’m missing something, but I thought hyperthermia was a late sign of MH. If there wasn’t increased EtCO2 not responsive to increasing MV, then this probably wasn’t MH to begin with?

 

[deleted162650]

IM sux, tube, dantrolene

 

[Arch Guillotti]

For the second one I would give em the jaw thrust and if nothing then place a tube down with a miller 2.

Jaw thrust has surely already been attempted and everyone knows to do this already. So you are going to intubate a 2 y/o with a Miller 2?

 

[deleted162650]

Jaw thrust has surely already been attempted and everyone knows to do this already. So you are going to intubate a 2 y/o with a Miller 2?

Just the tip.

 

[Psai]

Jaw thrust has surely already been attempted and everyone knows to do this already. So you are going to intubate a 2 y/o with a Miller 2?

Anyone can be intubated with a miller 2

 

[nimbus]

IM roc, tube, IV, sugammadex

 

[T-burglar]

Try not to attempt panicked bagging that will only fill the stomach. Have roc on a syringe with a 25 g needle (as I always have on me) , as the CVP rises with hypoxia and hypercarbia you can usually see EJ veins start to stand out on the neck and elsewhere. Stick the needle into the vein, aspirate blood, inject roc.

 

[Ronin786]

You've got an antidote for MH (dantrolene) and you've got an antidote for laryngospasm (sux).

Dart the kid and call for the cart.

The other option is IM rocuronium/vecuronium. Onset time won't be as quick as sux, but it has been described. Especially with sugammadex available nowadays.

And as always, I'm calling for an extra set of hands from the beginning.

 

[deleted162650]

Hypoxia reliably breaks laryngospasm.

 

[WholeLottaGame7]

I'm not convinced enough that the first episode was MH to not give IM sux, but if you're conservative, IM roc is also an option.

Occ you can get the tube through the cords without relaxation, but you don't want to jack them up and cause bleeding and swelling that may make intubating later difficult.

 

[propadope]

Suction. If secretions present then PPV will simply push them into the airway and worsen the spasm

Agree with IM sux and MH cart

I would consider an IO if available and US.

Call ENT for surgical airway if available

Could try LTA under direct vision or through an NPA if unable to do a laryngoscopy

Consider needle cricothyrotomy

 

[Noyac]

Well I’m not a resident of a pedi fellowship person but I agree with giving the sux and dealing with MH if it does occur.

The only thing I will add is when faced with a laryngospasm in a child, or anyone for that matter, that does not have IV access I will inject in the tongue rather than the shoulder or thigh or wherever one chooses to place an IM injection. The tongue is a highly vascular muscle and it’s been a long time but I believe the uptake is about the fastest muscle of any. And it’s right there.

 

[anbuitachi]

get the kid tested. elevated temperature in a small kid? maybe they cooked the kid with warmers.

and keep it simple. sure put on some MH filters, flush the machine. get an IV, and push prop, and intubate. run prop infusion maintenance

if its laryngospasm and cant be broken with propofol, ppv, jaw thrust, then give sux. i think its all risk benefit ratio and the risk here of dropping dead due to laryngospasm >>> the minimal risk of MH.

 

[Libertas]

Perhaps easier than tongue, but same idea, is the submental injection in the soft tissue below the chin. Bonus is that it doesn’t disrupt masking.

 

[nimbus]

Well I’m not a resident of a pedi fellowship person but I agree with giving the sux and dealing with MH if it does occur.

The only thing I will add is when faced with a laryngospasm in a child, or anyone for that matter, that does not have IV access I will inject in the tongue rather than the shoulder or thigh or wherever one chooses to place an IM injection. The tongue is a highly vascular muscle and it’s been a long time but I believe the uptake is about the fastest muscle of any. And it’s right there.

Perhaps easier than tongue, but same idea, is the submental injection in the soft tissue below the chin. Bonus is that it doesn’t disrupt masking.

And if you get an unintended intravascular injection, that’s even better.

 

[Mman]

Well I’m not a resident of a pedi fellowship person but I agree with giving the sux and dealing with MH if it does occur.

The only thing I will add is when faced with a laryngospasm in a child, or anyone for that matter, that does not have IV access I will inject in the tongue rather than the shoulder or thigh or wherever one chooses to place an IM injection. The tongue is a highly vascular muscle and it’s been a long time but I believe the uptake is about the fastest muscle of any. And it’s right there.

I've only had to give IM sux emergently once to a kid and I stuck them in the deltoid and it broke the spasm in < 5 seconds. Maybe it was coincidence but it amazed me at how fast it broke. It isn't nearly as long as waiting for an IV dose to get somebody to start/stop fasciculating. Just takes a few molecules to hit the right receptors and the spasm will break.

 

[Noyac]

I've only had to give IM sux emergently once to a kid and I stuck them in the deltoid and it broke the spasm in < 5 seconds. Maybe it was coincidence but it amazed me at how fast it broke. It isn't nearly as long as waiting for an IV dose to get somebody to start/stop fasciculating. Just takes a few molecules to hit the right receptors and the spasm will break.

What dose?
Something is not adding up in my head. How can IM be faster than IV?
What was the kids O2 Sats?

 

[somedumbDO]

If they don't have king denborough, multi mini core or central core i don't give a flying. Gas em down, iv then fiberoptic tube with small amount of prop and fent.

For the second one I would give em the jaw thrust and if nothing then place a tube down with a miller 2.

I agree 100% but what if mom is a card carrying member of the parents w mh kids club. The last two non triggering anesthetics put you in a bind?

 

[somedumbDO]

IM sux, tube, dantrolene

Well im sux tube, io/cvl, dantrolene? Would you give it right away or wait for symptoms?

 

[somedumbDO]

IM roc, tube, IV, sugammadex

Dose of roc? What is onset? Do you feel it's equivalent to sux?

 

[somedumbDO]

Hypoxia reliably breaks laryngospasm.

60 percent of the time it works every time- Ron burgundy

 

[nimbus]

Dose of roc? What is onset? Do you feel it's equivalent to sux?

Never tried it. Only read about it. Imagine a bigger dose is better....so I’ll guess 2mg/kg

 

[deleted162650]

Well im sux tube, io/cvl, dantrolene? Would you give it right away or wait for symptoms?

Wait for symptoms in this kid that I’m 98% sure doesn’t actually have MH.

 

[ethilo]

Just found this...

Anesthesiology. 1996 Aug;85(2):231-9.
Intramuscular rocuronium in infants and children. Dose-ranging and tracheal intubating conditions.
Reynolds LM1, Lau M, Brown R, Luks A, Fisher DM.

"In phase I, 5 of 7 patients given quadriceps injections (1,200-2,200 micrograms/kg) had slow onset of twitch and ventilatory depression. With deltoid injections (800-2,400 micrograms/kg), all patients developed complete twitch depression; median time to 50% depression of minute ventilation was 3.2 min in infants and 2.8 min in children. In phase II, intubating conditions were consistently adequate or good-excellent at 2.5 min in infants and 3.0 min in children. Initial twitch recovery was at 57 +/- 13 min (mean +/- SD) in infants and 70 +/- 23 min in children."

conclusion:
Deltoid injections of rocuronium, 1,000 micrograms/kg in infants and 1,800 micrograms/kg in children, rapidly permit tracheal intubation in infants and children, despite a light plane of anesthesia. Duration of action of these large doses might limit clinical utility.

 

[daneeka]

get the kid tested.

Where I am, kids younger than 10 can't get an IVCT. I think the absolute lower limit is 4 years. Genetic screening isn't sensitive enough unless you know which mutation you're dealing with.

 

[anbuitachi]

Where I am, kids younger than 10 can't get an IVCT. I think the absolute lower limit is 4 years. Genetic screening isn't sensitive enough unless you know which mutation you're dealing with.

thats pretty cool

 

[Libertas]

Where I am, kids younger than 10 can't get an IVCT. I think the absolute lower limit is 4 years. Genetic screening isn't sensitive enough unless you know which mutation you're dealing with.

Thought the genetic testing is sensitive, but not specific?

 

[daneeka]

Thought the genetic testing is sensitive, but not specific?

No, while most mutations are in the RYR1 gene (ryanodine receptor), not all are. Additionally, it isn't always possible to predict which alterations to the RYR1 gene will give rise to the MH phenotype. Therefore sensitivity is low unless the patient is likely to have inherited a known mutation among those commonly tested for.

The in-vitro contracture testing (i.e. a muscle biopsy) is sensitive but not specific - maybe that's what you're thinking of?

European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility

 

[Mman]

What dose?
Something is not adding up in my head. How can IM be faster than IV?
What was the kids O2 Sats?

it was something like 3 or 4 mg/kg with sats in the low 70s and dropping quick. I think the "how can it work faster than IV" is because it doesn't, but you only need such a minimal response to break laryngospasm. I mean when you give a drug IM, a small part of it will get into a vein almost immediately because those muscles are pretty vascular.

I bet if you gave sux IV it would break laryngospasm much faster than the time we usual have to wait to see fasciculations.

This was more than 10 years ago so the memory is slightly fuzzy, but I vividly remember being amazed at how fast it kicked in.

 

[somedumbDO]

I think we already beat this horse to death so Ill just review what happened. Story could of been MH remember sometimes it takes a couple of exposures to volitile to elicit a response, mom demanded non triggering anesthetic. Premed kid with PO versed we have these fancy "Poppers" no not that kind.... but compressed air and lidocaine to numb the skin for IV. Kid ended up tough IV stick and after the third attempt was screaming..... IM ketamine/glyco/versed. doing ok, attempt another IV failed.... then spasms. We are all trained what to do, jaw thrust, PPV, it wasn't budging, 50% of my practice is kids I know how to break a spasm. I call for a second set of hands while drawing up IM roc. Had a brief conversation with head of peds anesthesia, she wanted to give suxs (airway trumps MH?), and was questioning as I pushed 2mg/kg w a 25 g needle under tongue. Worked like magic! I have done this with atropine in the past in emergent situation but never with roc. 15-20 sec felt it melt away. Intubated and they did an EJ PIV. case continues.

 

[dhb]

EJ PIV

The bomb.
I had a day of hard sticks and put in a couple with ENT kinda freaking out cause she's not really used to have someone put them in. But she told me later that since the kids didn't see it they didn't complain about it as much as a piv.

 

[Arch Guillotti]

If they don't have king denborough, multi mini core or central core i don't give a flying. Gas em down, iv then fiberoptic tube with small amount of prop and fent.

For the second one I would give em the jaw thrust and if nothing then place a tube down with a miller 2.

This type of answer will get you nowhere on oral boards or in real life.

The answer is to give IM roc wherever you feel is best or to give sux and roll the dice.

 

[deleted9493]

If I am using IM roc electively for difficult access cardiac babies who won’t tolerate an immobilizing dose of anything, I’ll split the dose into both arms to move things along.

Can confirm that onset of blockade after quadriceps injection is a lot slower than deltoid. I’d bet that a single injection of sux is comparable in onset to bilateral deltoid roc though I have no data to back that up.

 

[dhb]

If I am using IM roc electively for difficult access cardiac babies who won’t tolerate an immobilizing dose of anything, I’ll split the dose into both arms to move things along.

Can confirm that onset of blockade after quadriceps injection is a lot slower than deltoid. I’d bet that a single injection of sux is comparable in onset to bilateral deltoid roc though I have no data to back that up.

Double Roc shot to the deltoids HARDO move!

 

[Planktonmd]

IM sux, tube, dantrolene

Just fantastic!