# Trismus



## sleepless near seattle (Oct 11, 2012)

Strange case last night.  Curious for input.  I know the devil is in the details, but I'll try to keep it simple.  
62 y/o fem initial c/o pain assoc with recent Dx of shingles.  Pt is conscious upon initial transport by BLS crew in rural community (approx 40 min from hospital).  ALS upgrade called for with update of possible CVA, no vitals.  Updates en route as follows:
 19:25 Pt in and out of consciousness BP 78/52, HR 72
 19:28 BP 50/28, no further
OS w/ original responders (now ~20 min from ER) as they began to ineffectively attempt BVM.  Pupils fixed @ 5mm, quick move to our unit, LP12 Fastpatch reveals an irregular sinus rhythm with a pulse, no spontaneous resps, unable to get a BP.  1st Responders relay pt took a "bunch" of vicodin for the shingles pain prior to calling 911.  Pt is in what I would call trismus, jaws clenched, no possibility of an OPA.  NPA placed and head repositioned while my partner gets an 18G in L AC and starts NaCl drip WO.  With head repositioned BVM breath goes in and produces copious amts of coffee ground emesis.  Airway suctioned and continue with BVM, .4 of narcan= no change.  BSL = 40, 25g D-50 = no change.  Prepare for RSI with 50 propofol then 100 succs= NO CHANGE!  Trismus persists and I mean rigid, clenched teeth, absolutely NOTHING is going in the mouth.  Can suction the cheeks as they continue to fill with coffee ground emesis, but that's it.  Pt is only on Valtrex and prn vicodin for the shingles, no other Rx and NKDA. At about 10 min out, I placed a call to med control, gave a full report and asked for advice on the airway as the pt began to brady down.  The Dr. didn't believe the situation but advised a second dose of succs and reattempt the airway, force it open if necessary.  CPR was begun, 2nd dose of succs again had no effect.  Rolled through the doors of the ER at that point and Dr then saw and believed.  He then took his own advice and forced the jaws open with stacked tongue blades that began to splinter in the process and intubated with a video assisted laryngoscope, the jaws remained exactly where they were placed with no rebound or bite block needed.  The pts status did not ever change and death was called in the ER.
The only thing I feel like I missed in reviewing my own report was enough time from when the pt brady'd down to asystole until we hit the doors of the ER that I should have switched gears into ACLS asystole protocols.  I don't believe this would have had any effect on the outcome, but nonetheless I should have at least got some epi on board.  Very curious to hear the results of autopsy but in the meantime would appreciate any feedback, especially if anyone has had similar experience.


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## Jambi (Oct 11, 2012)

My mind immediately goes to whether or not the clenched jaws was a result of muscular action or mechanical action/fixation (mandible)?

Was it just the jaws that were clenched or where there any other areas experienced muscular contraction?  Where neck muscle clenched?

I don't doubt what you're saying, I just don't know how the muscles could have withstood being depolarized..unless it was a weird presentation of a fasciculation that then didn't dissipate?

I suppose there could have been some other reaction occurring from some as yet unknown medication or substance?

Regardless, damn, that's a crappy call.


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## Jambi (Oct 11, 2012)

Also, the above are just some of my random musings...

I bet Vene or others could offer some useful input.


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## FLdoc2011 (Oct 11, 2012)

Doesn't sound like you could have done much more or that anything would have made a difference.   Were initial vitals ok?  

Only thing is I probably wouldn't have given a propofol bolus to someone with a BP in the 50's, especially if they were already obtunded.  

What other RSI drugs do you have available?


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## Jambi (Oct 11, 2012)

So apparently Trimus is a rare side effect of succinylcholine.

http://emj.bmj.com/content/22/6/456.full

Note the evidence of the case report of a hypotensive patient with evidence of major blood loss, specifically GI.


And here is some random pdf I found, I don't claim that it's valid, but here it is.
http://www.mtems.com/documents/training/neversaynever.pdf


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## sleepless near seattle (Oct 11, 2012)

Thanks, 
no known other causes, mechanical or chemical.  Considered fasciculations at the time, but the teeth were clenched rock solid prior to succs.


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## sleepless near seattle (Oct 11, 2012)

Good catch on the propofol with regards to BP.  Was behind the 8 ball so far already I honestly didn't consider it.


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## DrankTheKoolaid (Oct 11, 2012)

*re*

strike that, just re-read the order of events


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## Jambi (Oct 11, 2012)

Corky said:


> strike that, just re-read the order of events



Perhaps not an option.  I know where I am, it's not an option.

Surgical/needle cric could have been an option as well, though like in my area, that is also not an option.


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## DrankTheKoolaid (Oct 11, 2012)

*re*

Yeah having re-read that the second after i posted, noted my error in the timeline.  And I would hope any area that is intubating has nasal intubation also in place.  Especially when there are contraindications to RSI or other pharmacological assisted intubations.

Certainly not a often used skill, but it has saved my patients arses the times I have had to do it.  But then again im in backwards *** California and we dont have RSI..........  Makes me a sad panda actually


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## sleepless near seattle (Oct 11, 2012)

FLdoc2011 said:


> Doesn't sound like you could have done much more or that anything would have made a difference.   Were initial vitals ok?
> 
> Only thing is I probably wouldn't have given a propofol bolus to someone with a BP in the 50's, especially if they were already obtunded.
> 
> What other RSI drugs do you have available?



Like I said earlier, good catch on the propofol.  It won't happen again.
Versed is the other primary sedative we have for RSI, our MPD REALLY REALLY likes and prefers we use propofol on almost everything, so I admit to a little tunnel vision there.  Other sedatives we have are valium (if it's available) or can sub that with ativan.  We don't carry Etomidate.  Fentanyl & M.S. (again, if available) for analgesics.


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## sleepless near seattle (Oct 11, 2012)

sleepless near seattle said:


> Like I said earlier, good catch on the propofol.  It won't happen again.
> Versed is the other primary sedative we have for RSI, our MPD REALLY REALLY likes and prefers we use propofol on almost everything, so I admit to a little tunnel vision there.  Other sedatives we have are valium (if it's available) or can sub that with ativan.  We don't carry Etomidate.  Fentanyl & M.S. (again, if available) for analgesics.



..and yes, according to first responders report, pt initially a+oX3, BP 120s/70s, unknown rate.


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## sleepless near seattle (Oct 11, 2012)

Jambi said:


> Perhaps not an option.  I know where I am, it's not an option.
> 
> Surgical/needle cric could have been an option as well, though like in my area, that is also not an option.



We do have cric kits as an option and I did consider it, didn't like it enough to try though.  Drs at ER both agreed it was an option to consider also but stated they were glad we didn't do it.  They haven't seen many go well, even in the hospital, let alone pre-hosptial.


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## fast65 (Oct 11, 2012)

sleepless near seattle said:


> We do have cric kits as an option and I did consider it, didn't like it enough to try though.  Drs at ER both agreed it was an option to consider also but stated they were glad we didn't do it.  They haven't seen many go well, even in the hospital, let alone pre-hosptial.



May I ask why you didn't like it enough to try it? This is truly a case where it seems like a cric was the only viable option at the time, there's always a risk associated with them, but honestly, it was this patients only real shot at an airway in the field. 

That being said, doesn't really sound like there was much you could have done unfortunately. You managed this patient to the best of your ability, and that's really all ya can ask for.


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## sleepless near seattle (Oct 11, 2012)

fast65 said:


> May I ask why you didn't like it enough to try it? This is truly a case where it seems like a cric was the only viable option at the time, there's always a risk associated with them, but honestly, it was this patients only real shot at an airway in the field.
> 
> That being said, doesn't really sound like there was much you could have done unfortunately. You managed this patient to the best of your ability, and that's really all ya can ask for.



Don't really have a good answer for you.  BVM was moving air though admittedly not very effectively, the 20 minutes in the rig seemed like 2 when it was all over.


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## usalsfyre (Oct 11, 2012)

sleepless near seattle said:


> We do have cric kits as an option and I did consider it, didn't like it enough to try though.  Drs at ER both agreed it was an option to consider also but stated they were glad we didn't do it.  They haven't seen many go well, even in the hospital, let alone pre-hosptial.



Once he arrested I would've picked up the scalpel. They were right, it probably wouldn't go well. But is it going to go much worse at that point?


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## sleepless near seattle (Oct 11, 2012)

Thinking I need to clarify.  I'm pretty confident that nothing would have changed the outcome, though I do appreciate the suggestions and will consider all of them on future calls.  Was hoping somebody might have had a similar experience in which paralytics didn't work.


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## sleepless near seattle (Oct 11, 2012)

usalsfyre said:


> Once he arrested I would've picked up the scalpel. They were right, it probably wouldn't go well. But is it going to go much worse at that point?



Good point.  Couldn't get the tube, if I thought pt needed that, than I should have been more willing to keep being aggressive with a cric.


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## Jambi (Oct 11, 2012)

sleepless near seattle said:


> Thinking I need to clarify.  I'm pretty confident that nothing would have changed the outcome, though I do appreciate the suggestions and will consider all of them on future calls.  Was hoping somebody might have had a similar experience in which paralytics didn't work.



Did you catch the link to the case study I linked?


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## Veneficus (Oct 11, 2012)

Do I understand correctly?

The trismus existed prior to the succs?

You were suctioning digested blood?

The pt was dx with shingles, did you see any evidence of this on the temporal region or face?

Was it localized to the thorax in a stereotypical dermatone pattern?


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## sleepless near seattle (Oct 11, 2012)

Jambi said:


> Did you catch the link to the case study I linked?



Yes, read the article.  Very similar on many counts and does lend itself to the idea that the succs didn't help, but also the succs wasn't the cause of the trismus either, it was already present.


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## sleepless near seattle (Oct 11, 2012)

Veneficus said:


> Do I understand correctly?
> 
> The trismus existed prior to the succs?
> 
> ...



Yes trismus prior to succs.  Yes coffee ground emesis that eventually just turned to brown fluid with out much "coffee grounds".  Curiously did NOT see the "chicken pox" or anything similar anywhere on the body.  Though pt was on Rx for it (Valtrex and vicodin prn).


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## mycrofft (Oct 11, 2012)

Ah, a non-sudden arrest.

OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?

I saw very similar picture in a pt who OD'ed on a handful of various meds including psych and pain meds. I can imagine also a localized central CVA causing that combination of effects without unilaterality. (Boy did spellcheck hate THAT one!).
"SHINGLES"  may equal


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## Veneficus (Oct 11, 2012)

mycrofft said:


> Ah, a non-sudden arrest.
> 
> OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?
> 
> ...



Temporal arteritis is sometimes misdiagnosed as shingles.


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## sleepless near seattle (Oct 11, 2012)

mycrofft said:


> Ah, a non-sudden arrest.
> 
> OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?
> 
> ...



Not sure if your replying to me or Vene.  The shingles really didn't concern me much, outside of the possibility that whatever her infection process was may have affected CNS and/or respiratory and therefore somehow blocked the effectiveness of the paralytic.


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## mycrofft (Oct 11, 2012)

Just tossing more clams in the kettle, as it were.
BTW, temporal arteritis:






and:

http://en.wikipedia.org/wiki/Giant-cell_arteritis

Very interesting. I can see where it could MAYBE be misdiagnosed due to serum crusts and I assume localized pain, but absence of a dermatomic outline and frank vesicles or the succession of stages to them (red, itchy/burny, vessiculation) should steer one to consider alternatives. 

Thanks for this thread and replies, I'm learning something new! This is a really potentially horrendous disease.


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## Veneficus (Oct 11, 2012)

mycrofft said:


> Just tossing more clams in the kettle, as it were.
> BTW, temporal arteritis:
> 
> 
> ...



In the early stages around the eye and face it looks just like shingles.

Slightly swollen, red, and terribly painful.


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## mycrofft (Oct 11, 2012)

Roger painful, shingles burns like fire and tender. Learning more.
OP, again thanks for this thread!


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## Veneficus (Oct 11, 2012)

Sometimes in severe trauma and burns, there is mucous breakdown and subsequent upper GI bleed in the stomach.

Since this is inflammatory mediated, I can find no reason a medical cause of severe or systemic inflammation could not do the same.


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## mycrofft (Oct 11, 2012)

Back to the red fish though. If you said "dropping BP, GI bleed" I'd be thinking gastric or esophageal vascular accident. What would account for trismus, cerebral hypoxia due to lost circulation? 

As for cricothyrotomy, if air WAS going in past the teeth, and a true cric could not be established (to get past the blood etc in the upper airway), I don't see where a cric could have made much difference, unless debris was occluding airway through the teeth. 

I wonder if the deceased had a positive rectal guaiac?

EDIT:
Intracranial necrotizing arteritis could give CVA like effects, while temporal arteritis could yield the "shingles" affect. Assuming the "shingles" wasn't a red herring.


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## FLdoc2011 (Oct 11, 2012)

Not sure I'd put GCA (giant cell arteritits) high on my DDx here.  Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills.  She was already going hypotensive and with some propofol may have just bottomed out and coded from that.   

Not sure how to explain the trismus... possibly seizure?   Were her limbs/extremities rigid?    

Just looking at some case reports of trismus with GCA, but doesn't seem to be that common,  classically it's jaw claudication with chewing.  And this just seems such an acute crash for that. 

Was the IV working?  Maybe the succs just didn't get circulated enough, she was already in shock and maybe even arrest at that point?


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## d_miracle36 (Oct 11, 2012)

Could it be instantaneous trismus?


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## d_miracle36 (Oct 11, 2012)

d_miracle36 said:


> Could it be instantaneous trismus?



Rigor I mean.


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## sleepless near seattle (Oct 11, 2012)

FLdoc2011 said:


> Not sure I'd put GCA (giant cell arteritits) high on my DDx here.  Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills.  She was already going hypotensive and with some propofol may have just bottomed out and coded from that.
> 
> Not sure how to explain the trismus... possibly seizure?   Were her limbs/extremities rigid?
> 
> ...



IV was good, wondered the same thing, withdrew, got good return and continued to flush, 1000mL bag in by the time we reached ER.


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## MadMedic (Oct 12, 2012)

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.


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## MrBooger (Oct 12, 2012)

sleepless near seattle said:


> The only thing I feel like I missed in reviewing my own report was enough time from when the pt brady'd down to asystole until we hit the doors of the ER that I should have switched gears into ACLS asystole protocols.  I don't believe this would have had any effect on the outcome, but nonetheless I should have at least got some epi on board.



If you aren't able to get any O2 into the lungs at any point, then doing everything you can for the heart would have ended up being pointless, but if the ER doc was able to get an airway, then the patient may have had a chance if you kept the circulation going (but not a good chance). If you really want to sit up thinking the scenario over in your head, you could have given Atropine while brady but the patient was unstable and brady so you would have needed to move to pacing immediately. This would have hopefully kept you from entering the asystole algorithm in the first place.  How effective would pacing a patient for 10 minutes be with no O2 being delivered? Depends on the venous reserve and other things, but the patient likely would have had unreversible brain damage from the hypoxia. All in all, you lost a patient which sucks, but personally I don't think you could have done anything different that would have saved them. Try not to lose sleep over it. We are only human and do the best we can.


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## Veneficus (Oct 12, 2012)

FLdoc2011 said:


> Not sure I'd put GCA (giant cell arteritits) high on my DDx here.



It is unnaturaly high on my differential in people suspected of shingles because I seen the results when it is misdiagnosed. It is an easy mistake to make, especially from the epidemiology standpoint and many providers I have met don't even remember GCA is a disease or how it presents.



FLdoc2011 said:


> Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills.  She was already going hypotensive and with some propofol may have just bottomed out and coded from that.



I agree, very hard to say, but if there was truly coffee ground emesis, then I would lean towards her taking a bunch of opioids for a very bad pain that wasn't going away. Aneurysm or the like.

Assuming no equipment or procedure failure, the clenched jaw has to be from a local calcium release or neuro trigger. It doesn't seem like tetanus.  



FLdoc2011 said:


> Not sure how to explain the trismus... possibly seizure?   Were her limbs/extremities rigid?.



This is what os getting me, I was searching for causes of masseter tetany outside of succs admin,  but so far came up empty.    



FLdoc2011 said:


> Just looking at some case reports of trismus with GCA, but doesn't seem to be that common,  classically it's jaw claudication with chewing.  And this just seems such an acute crash for that.



I was figuring the arteritis was diffuse and the trismus was secondary to the crash. I read a couple of case reports of it on OD as well. But I can find nothing on GI bleeding from acute opioid OD. Which leads me back to she was self medicating for something more severe and probably undiagnosed than shingles.

As I am sure you know more than me, as you are one of those medicine guys, shingles often presents when there is some other decompensation somewhere. 



FLdoc2011 said:


> Was the IV working?  Maybe the succs just didn't get circulated enough, she was already in shock and maybe even arrest at that point?



If she had a ruptured aneurysm or esophageal varices, then succs likely would never have circulated in any effective way.

If I recall correctly there was no mention of shocks or vfib in the original post, which fits with a bleed.


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## akflightmedic (Oct 12, 2012)

Very interesting. I certainly wish we had more information specifically regarding ALL medicines and any acute/chronic conditions.

While they mentioned the valtrex and shingles, etc was that everything? I cannot help but feel there is something missing which is quite significant.

Did she have a UTI? Was she taking anything for it?
Tetanus was a fleeting thought but ruled out quickly.
Could she have had a coincidental TMJ issue?

I am leaning towards a very simple answer for the trismus and suspect several unrelated events may have simply occurred closely together resulting in post death mass confusion.

Continue with the dissection as it has been quite informative and if you are able to get any follow up information from the pathologist that would be great to hear.

As for the airway issue, surgical cric would have been done early on. Not QB'ing you, just saying there would have been no hesitation but I back that with only personal experience of the services I used to work for--it was never taboo or frowned upon.


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## mycrofft (Oct 12, 2012)

*Remember House's Rule: Pt's Lie (or at least can be bad historians)*



sleepless near seattle said:


> Yes trismus prior to succs.  Yes coffee ground emesis that eventually just turned to brown fluid with out much "coffee grounds".  Curiously did NOT see the "chicken pox" or anything similar anywhere on the body.  Though pt was on Rx for it (Valtrex and vicodin prn).


_
"19:25 Pt in and out of consciousness BP 78/52, HR 72
19:28 BP 50/28, no further"_ 
_"Can suction the cheeks as they continue to fill with coffee ground emesis, but that's it" _Decompensating, probably descending down the decomp curve at a very steep rate.

_With head repositioned BVM breath goes in _ Airway patent enough, although disregrding aspiration for that moment



OK, stepping around shingles and  unknown causes, just these say "big GI bleed, pt going downhill very rapidly". Was the pt taking NSAIDS?

Trismus? What pain meds was she getting, exactly? Were psych meds or antiseizure meds being given off-label for chronic pain relief? Was the pt self-dosing?

The sidetracks are fascinating, but we haven't gotten a firm set of possibilities for the trismus. Also, although in a pt with their bloody stomach contents mysteriously issuing (vomiting, or just slipping up the esoph?), what measures were needed for an airway with a pt whom a BVM was ventilating but had this pro-pharyngeal junk? Nasophryngeal suctioning as low suction? Slipping an old-fashioned thin suction catheter behind some molars and trying to do that? (And do either of those without causing gagging?).


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## sleepless near seattle (Oct 12, 2012)

mycrofft said:


> _
> "19:25 Pt in and out of consciousness BP 78/52, HR 72
> 19:28 BP 50/28, no further"_
> _"Can suction the cheeks as they continue to fill with coffee ground emesis, but that's it" _Decompensating, probably descending down the decomp curve at a very steep rate.
> ...



We did suction the npa with a 14 french and got a fairly sig return.  For all others that keep raising the other meds/ other medical prob questions: I've relayed everything we were told, have already been wondering if she was self medicating with u/k meds and was assuming that night that there was something, maybe many things, going on besides the shingles (if THAT was even properly diagnosed) causing the GI bleed and respiratory arrest.  Can only go by what we're told, but always have assumed there was more to the story.  Again, I'm not losing sleep over this, really just wondering what kind of input others have.  Lots of good ideas out there, I really appreciate the input.  Please don't think that I feel like I did everything right, I really do appreciate everyone's ideas specifically about things I may have done differently or added/considered.  I think that's what a site like this is all about, different perspectives to help us all learn and be more proficient and efficient in the future.  Rest assured however, I still believe that nothing was going to change the outcome of this pt.  I've only been a medic for a couple years but have been an EMT-I on the same crew for 10+ years and am very comfortable / pragmatic about pt outcomes.  I knew very early in this call that there was going to be very little I could do to change her outcome, though I did & will always try everything I can anyway with hope that I'm wrong and that miracles can happen.


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## mycrofft (Oct 13, 2012)

Good to know you're all right.


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## sleepless near seattle (Oct 13, 2012)

mycrofft said:


> Good to know you're all right.



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


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## jwk (Oct 14, 2012)

MadMedic said:


> 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.
> 
> ...



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.


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## mycrofft (Oct 14, 2012)

*Thanks JWK!*

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


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## Melclin (Oct 14, 2012)

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.


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## triemal04 (Oct 14, 2012)

Melclin said:


> Someone may have mentioned this already but how about dodgy sux?
> 
> Its temp sensitive or maybe you just had a bad batch.
> 
> ...


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.


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## mycrofft (Oct 14, 2012)

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.


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## triemal04 (Oct 14, 2012)

mycrofft said:


> 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.


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## jwk (Oct 14, 2012)

triemal04 said:


> 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.


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## 18G (Oct 15, 2012)

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.


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## Christopher (Oct 15, 2012)

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


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## usalsfyre (Oct 15, 2012)

Christopher said:


> 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.


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## Christopher (Oct 15, 2012)

usalsfyre said:


> 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.


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## sleepless near seattle (Oct 15, 2012)

Melclin said:


> Someone may have mentioned this already but how about dodgy sux?
> 
> Its temp sensitive or maybe you just had a bad batch.
> 
> ...



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.


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## jwk (Oct 15, 2012)

Christopher said:


> 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.
> 
> ...



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.


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## Aidey (Oct 15, 2012)

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


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## coolidge (Oct 15, 2012)

*any value of placing two nasal airways*

Any value of placing two nasal airways and bagging?


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## NomadicMedic (Oct 15, 2012)

coolidge said:


> 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


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## Christopher (Oct 15, 2012)

jwk said:


> 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.


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## mycrofft (Oct 15, 2012)

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?


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## NomadicMedic (Oct 16, 2012)

mycrofft said:


> 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?



No. You place an ET tube with a cuff to keep ventilations from escaping and to hopefully prevent further aspiration.


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## mycrofft (Oct 16, 2012)

Oh, I was still thinking "Father Mulcahey and Radar" cric. Good!


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## triemal04 (Oct 16, 2012)

jwk said:


> 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.


Sure, I get that, and with a couple doses given I agree that not having ANY change would be odd.  It just seems that the first thing to consider in this case would be the simplest and easiest correctable solution, which would be that, for whatever reason, the sux isn't working, and to try something new.  As the OP described it the pt was allready apneic, so you can't even gauge if there'd been an effect by looking at their respiratory rate/pattern.

I don't know if there's more info out there, but the abstract I linked to, while only showing pretty small decreases in strength after 4-6 weeks at 25C did mention that at 40C the rate was higher.  I don't know how the OP's department works, but it's far from unheard of for rigs parked in an apparatus bay to get damned hot during the summer months.  Hitting 100F might be pushing it, but over 75F would be pretty routine until the engine was turned on.  For people keeping sux uncooled until the manufacturers expiration (as it appears the OP does) something to think about.

And I'm still very curious if/when the ER doc pushed his own paralytic, and what it was.


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## sleepless near seattle (Oct 17, 2012)

triemal04 said:


> Sure, I get that, and with a couple doses given I agree that not having ANY change would be odd.  It just seems that the first thing to consider in this case would be the simplest and easiest correctable solution, which would be that, for whatever reason, the sux isn't working, and to try something new.  As the OP described it the pt was allready apneic, so you can't even gauge if there'd been an effect by looking at their respiratory rate/pattern.
> 
> I don't know if there's more info out there, but the abstract I linked to, while only showing pretty small decreases in strength after 4-6 weeks at 25C did mention that at 40C the rate was higher.  I don't know how the OP's department works, but it's far from unheard of for rigs parked in an apparatus bay to get damned hot during the summer months.  Hitting 100F might be pushing it, but over 75F would be pretty routine until the engine was turned on.  For people keeping sux uncooled until the manufacturers expiration (as it appears the OP does) something to think about.
> 
> And I'm still very curious if/when the ER doc pushed his own paralytic, and what it was.



No further paralytic in the ER.  Just the prying with tongue blades as described originally.  The jaws then stayed right where he put them without the aid of a bite block.  Although not unheard of, it rarely reaches 80F on the Pacific Northwest Coast.


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