laryngospasm, no IV, peds patient with muscular dystrophy

[caligas]

---

Members don't see this ad.

This is a hypothetical question only. Do you give sux in case of severe laryngospasm with bradycardia?

Seems like your alternatives are to wait and pray or maybe try IM roc.

 

[pgg]

Sure, I would. Just give some atropine with it. Bradycardia in a kid is usually caused by hypoxia, so he's probably already hypoxic. By the time IM roc worked he'd be really really hypoxic.

 

[aneftp]

You do positive pressure, IM rocuronium, then give sux IM if they start to decompensate

 

[caligas]

You do positive pressure, IM rocuronium, then give sux IM if they start to decompensate

agreed the risk of hypoxic arrest outweighs the theoretical risk of hyperkalemia.

 

[IlDestriero]

This was essentially my oral board question.
If this is an unknown muscular dystrophy patient, not some other myopathy, mitochondrial dz, etc. I would never under any circumstance give Sux. You could induce an unresuscitatable hyperkalemic arrest. I would give a huge dose of IM ROC. The treatment would depend on the exact diagnosis. You could always try jet ventilation if the kid was going to die. I'd rather risk a treatable PTX then an untreatable hyperkalemic arrest. Besides hypoxia breaks laryngospasm, eventually.😉

 

[cincincyreds]

Thank god these things only happen on the oral boards.

How about just injecting rocuronium under the tongue which is very vascular. I've heard that could work under this disaster of a situation.

Then the next step is ENT.

 

[BobBarker]

Inject the roc like the kid is shooting up heroin.

 

[somedumbDO]

This was essentially my oral board question.
If this is an unknown muscular dystrophy patient, not some other myopathy, mitochondrial dz, etc. I would never under any circumstance give Sux. You could induce an unresuscitatable hyperkalemic arrest. I would give a huge dose of IM ROC. The treatment would depend on the exact diagnosis. You could always try jet ventilation if the kid was going to die. I'd rather risk a treatable PTX then an untreatable hyperkalemic arrest. Besides hypoxia breaks laryngospasm, eventually.😉

Well said, exactly what I wud do

 

[somedumbDO]

Thank god these things only happen on the oral boards.

How about just injecting rocuronium under the tongue which is very vascular. I've heard that could work under this disaster of a situation.

Then the next step is ENT.

This actually works pretty well n=2

 

[Precedex]

Personally I would just intubate the kid. Yes you may cause some vocal cord trauma but if you do your best to corkscrew the tube in fairly gently if shouldn't be too bad. I usually do this if airway maneuvers and propofol don't work, rarely ever give six and I've never used roc for this purpose. Now if it happens again after extubating then I might try something else.

 

[pgg]

I wish to change my answer upon more careful reading of the question (headline). The muscular dystrophy bit didn't register. 😳 No succ.

 

[Idiopathic]

IM roc under the tongue, IM atropine in the deltoid

 

[loveumms]

Once you become hypoxic enough, it's a great muscle relaxant. Put the tube in and then bring the sats back up.

Even with small doses, you may see hyperkalemia. "The hyperkalemia to succinylcholine is dose depen- dent. Extremely small doses of succinylcholine (0.1 mg/ kg) in denervation states can cause paralysis with no hyperkalemia.65 Despite this (single) observation, it is inadvisable to use succinylcholine in susceptible pa- tients, because the paralytic and hyperkalemic responses are unpredictable. In most patients, the succinylcholine- induced hyperkalemia lasts less than 10–15 min"

 

[soonerfrog]

Agree, no Sux. Indefensible if something untoward happened, hpyerkalemic or otherwise. Also agree that prob beat solution is waiting. Keep giving positive pressure...eventually, cords WILL relax. The good news is the ensuing, and VERY unsettling bradycardia is generally very responsive and fully corrective once PaO2 gets back above 60-90mmHG.

 

[Idiopathic]

Once you become hypoxic enough, it's a great muscle relaxant. Put the tube in and then bring the sats back up.

Even with small doses, you may see hyperkalemia. "The hyperkalemia to succinylcholine is dose depen- dent. Extremely small doses of succinylcholine (0.1 mg/ kg) in denervation states can cause paralysis with no hyperkalemia.65 Despite this (single) observation, it is inadvisable to use succinylcholine in susceptible pa- tients, because the paralytic and hyperkalemic responses are unpredictable. In most patients, the succinylcholine- induced hyperkalemia lasts less than 10–15 min"

im not sure this applies to MD states. The risk here is more from muscle breakdown than a denervated state, and as such, rhabdomyolysis with acute hyperkalemia and extremely high CK would be evident, this should be less likely to normalize spontaneously, as opposed to the depolarization phenomenon.

 

[Oggg]

A baby in laryngospasm will quickly desat and go bradycardic and then code fairly quickly. I don't have enough experience to know if you can watch a baby turn blue to stop the laryngospasm. I suppose IM atropine could give you some more time to wait for hypoxia to break the spasm, before bradycardia and death ensue.

 

[caligas]

A baby in laryngospasm will quickly desat and go bradycardic and then code fairly quickly. I don't have enough experience to know if you can watch a baby turn blue to stop the laryngospasm. I suppose IM atropine could give you some more time to wait for hypoxia to break the spasm, before bradycardia and death ensue.

Im with you. Sux is probably wrong but if sats are dropping and heart is slowing im going to give SOMETHING. I guess high dose IM roc with atropine, try to intubate, prepare for needle cric.

 

[IlDestriero]

A baby in laryngospasm will quickly desat and go bradycardic and then code fairly quickly. I don't have enough experience to know if you can watch a baby turn blue to stop the laryngospasm. I suppose IM atropine could give you some more time to wait for hypoxia to break the spasm, before bradycardia and death ensue.

You're correct. My comment, while true, was sarcastic. The young kids will brady down dramatically and you will be doing chest compressions.

 

[IlDestriero]

A baby in laryngospasm will quickly desat and go bradycardic and then code fairly quickly. I don't have enough experience to know if you can watch a baby turn blue to stop the laryngospasm. I suppose IM atropine could give you some more time to wait for hypoxia to break the spasm, before bradycardia and death ensue.

.

 

[loveumms]

I was not implying that one should wait for the kid to turn blue, I was just commenting that hypoxia leads to muscle relaxation eventually.

I would use high dose IM rocuronium or intubate with no relaxant. A little cord damage is better then a dead patient.

Idiopathic - the quoted information was from a 2005 review article in A&A "Succinylcholine-induced Hyperkalemia in Acquired Pathologic States". The point really was that even small doses can cause severe hyperkalemia. Upregulation of ach receptors will occur in both deinnervation states and MD.

 

[dillpickles]

What would be the dose of IM rocuronium (range and maximum) for laryngospasm?

Also, would injection in tongue be faster onset than in deltoid or elsewhere?

 

[Idiopathic]

I was not implying that one should wait for the kid to turn blue, I was just commenting that hypoxia leads to muscle relaxation eventually.

I would use high dose IM rocuronium or intubate with no relaxant. A little cord damage is better then a dead patient.

Idiopathic - the quoted information was from a 2005 review article in A&A "Succinylcholine-induced Hyperkalemia in Acquired Pathologic States". The point really was that even small doses can cause severe hyperkalemia. Upregulation of ach receptors will occur in both deinnervation states and MD.

thats fine, but i think the more clinically relevant problem is rhabdomyolsis, which is unlikely to be correctable as rapidly as 10-15 minutes

 

[Idiopathic]

What would be the dose of IM rocuronium (range and maximum) for laryngospasm?

Also, would injection in tongue be faster onset than in deltoid or elsewhere?

>1mg/kg, some people quote up to 8mg/kg 😱 you will obviously need to support ventilation for a long time afterwards, but if you need it, you need it.

the tongue is very vascular and drains into the IJ->SVC directly, it should not take that much longer than an IV injection for you to see an effect. that would be my site of choice in this scenario, assuming you dont have to give 10cc of volume or something silly like that

 

[dillpickles]

thanks!

 

[michigangirl]

You're correct. My comment, while true, was sarcastic. The young kids will brady down dramatically and you will be doing chest compressions.

IM atropine, IM Roc, chest compressions if this is an infant and heart rate <60 even if there is a pulse. Keep going with the CPAP and do your best to get the tube in-- someone should actively be putting in an IO while you're doing all this unless there's a massive vein popping up at them.

 

[IlDestriero]

- someone should actively be putting in an IO while you're doing all this unless there's a massive vein popping up at them.

I'm waiting for the chance.

 

[Planktonmd]

Muscular dystrophy is also a risk factor for malignant hyperthermia not only hyperkalemia.
So... if a kid has muscular dystrophy just get an IV before induction...

 

[Arch Guillotti]

Muscular dystrophy is also a risk factor for malignant hyperthermia not only hyperkalemia.
So... if a kid has muscular dystrophy just get an IV before induction...

I thought this assumption was tenuous at best. Can you provide a reference?

(not a thousand cut and paste jobs of questionable stuff?) 🙂

 

[caligas]

Muscular dystrophy is also a risk factor for malignant hyperthermia not only hyperkalemia.
So... if a kid has muscular dystrophy just get an IV before induction...

Good point. If sux is contraindicated its probably best to get the IV first after p.o. midaz or IM ketamine etc, regardless of MH concerns.

 

[Sublimazing]

Good point. If sux is contraindicated its probably best to get the IV first after p.o. midaz or IM ketamine etc, regardless of MH concerns.

Respectfully, of course if they've got a muscular dystrophy you're going to get an iv first...i think everyone assumed that this scenario was contingent on an iv not being possible...also what does ket/midaz have to do with mh?

 

[Precedex]

Duchennes is not a risk factor for MH but you can develop rhabdomyolysis with gas.

 

[Idiopathic]

Muscular dystrophy is also a risk factor for malignant hyperthermia not only hyperkalemia.
So... if a kid has muscular dystrophy just get an IV before induction...

beckers/duchennes are definitely not a risk factor for malignant hyperthermia.

 

[caligas]

Respectfully, of course if they've got a muscular dystrophy you're going to get an iv first...i think everyone assumed that this scenario was contingent on an iv not being possible...also what does ket/midaz have to do with mh?

For those of you mentioning needle crics, a lot of my attendings have seemed to bring this up during the induction pimping session, and I've even had to construct the contraption, but i haven't met anyone with first hand experience...does this work? Do you have to administer chest comp with the jet ventilation? What was the scenario?

Midaz or ketamine to help you get an IV.

Agree, best to have an IV before induction if sux cant be used.

 

[combatwombat]

This is a hypothetical question only. Do you give sux in case of severe laryngospasm with bradycardia?

Seems like your alternatives are to wait and pray or maybe try IM roc.

Does anyone do laryngeal nerve blocks or is this mostly a theoretical thing?

 

[Idiopathic]

Does anyone do laryngeal nerve blocks or is this mostly a theoretical thing?

kind of like comparing apples and ford f-150s. i know people that do laryngeal nerve blocks, but i dont know anyone who would plan to give sux to someone with muscular dystrophy, assuming people plan for these scenarios.

 

[painstop]

I have a colleague that works at an ASC where the nurses are less than helpful, to put it nicely. He does inhalational induction and intubates BEFORE starting the IV. Do you guys think this is defensible? I asked a peds expert and, after thinking about it, she said that it seemed reasonable to her if the nurses and surgeons aren't willing (or capable) to help hold the mask and the whole one-handed IV thing is simply too awkward. Any thoughts?

 

[Idiopathic]

seems like it would be hard to defend if you get into trouble but if its what you have to do its what you have to do

 

[soonerfrog]

Since when is MD of any variety a risk factor for MH? I'm open to new ideas but I've never seen this purported in any literature. Plank?

 

[Idiopathic]

Since when is MD of any variety a risk factor for MH? I'm open to new ideas but I've never seen this purported in any literature. Plank?

they are associated with MH-like conditions (cardiac arrhythmia, rhabdo, hyperkalemia, etc...) and given the acute nature of it, i think it was once assumed that these patients were more susceptible to MH, but this is not a reality.

central core disease is more strongly associated.

 

[Planktonmd]

they are associated with MH-like conditions (cardiac arrhythmia, rhabdo, hyperkalemia, etc...) and given the acute nature of it, i think it was once assumed that these patients were more susceptible to MH, but this is not a reality.

central core disease is more strongly associated.

True,
Now they are called "MH-like" manifestations, and could be very similar in presentation to MH:
They happen after exposure to inhaled agents, include severe rhabdo, hyperkalemia, acidosis and do respond to Dantrolene!

 

[reanimatore]

I will sometimes place an LMA after an inhalational induction, ensure spontaneous ventilation, keep them deep, then start an IV, then switch to ETT if needed for the case.

This is an interesting scenario. I frequently work in a burn unit, and it can be an unsettling feeling to know that sux is out of play when doing peds cases.

 

[Arch Guillotti]

seems like it would be hard to defend if you get into trouble but if its what you have to do its what you have to do

Agree. I know a very smart guy who gave sux to an MH-susceptible kid (kid didn't trigger though and did fine). Obviously very dire circumstances. Kids that crash and burn are very rare but until you have seen a kid start to die right in front of you there is no way to imagine how swiftly you have to react.