# Fentanyl and chest wall rigidity



## Shishkabob

Anyone ever have a patient develop chest wall rigidity post fentanyl administration?  I knew it could happen, I also knew it was rare, but I had it happen to me.


Had a trauma patient the other day bucked off a horse.  No chest trauma noted or felt, good expansion, good breathsounds, normal palpation.  100%RA, 40 ETCO2, all looking good.   I started him off at 50mcg of Fent. because he was a teen and had a possible head injury, so I wanted to take some of the pain away but still have him awake during transport.  He tolerated it well, so I gave another 25mcg after some time.

About 5 minutes after administration, he started to complain that it was a little hard to breathe, and that his chest felt hard.  Still good SPo2 and ETCo2 readings.  I looked and sure enough, there wasn't any chest wall movement.  I palpated, and it was noticeably stiffer.   I was slightly worried about a pneumo having formed due to his age / build and the original call, but he still had good breath sounds.


Needless to say I wasn't a happy camper, but I had him on O2 NC, and monitored him.  After another 5 minutes or so, he returned to normal with good expansion, no complaint of difficulty.  Anyone else ever see this?


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## usalsfyre

You probably pushed it too fast. Generally you only see chest wall rigidity with LARGE doses or rapid administration. The usual recommendation is to push it over 1-2min.  

In severe cases the treatment is a NMBA and intubation. That would for sure go under the category of "bad day".


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## Shishkabob

Yeah, I'd be lying if I said I did it over 1-2 minutes, but I didn't slam it either.  Guess 50mcg over 30+ seconds still isn't slow enough.




But hey, I DO need an intubation


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## Sandog

So does this side effect result from skeletal muscle rigidity or is it a result of depression of the phrenic nerve system? If the former what would be the action of the opioid on the skeletal muscle, calcium channel?

Just curious...


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## 18G

I've heard that the chest wall rigidity is most common in pediatrics than adults...

Linus... thanks for sharing your experience. I prob wouldn't have pushed it over a full 1-2min either but I will remember your experience for future reference.


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## Sam Adams

Ironically, a couple of us were talking about this a couple of shifts ago. I had never heard of it.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2163527/?page=1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2163527/?page=2

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2516388/?page=1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2516388/?page=2


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## 18G

Great article!


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## Sam Adams

I'll stop posting article links after this one. We all know how to use an internet search engine. This one describes a preterm neonate w/ chest wall rigidity due to maternal dosing. I haven't yet had the need to administer it to a gravid female. I'll certainly be thinking it through more thoroughly though ...

http://www.nature.com/jp/journal/v30/n2/full/jp200966a.html


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## 18G

No need to stop posting the valuable links.... its nice to have it all in one place... links and the discussion together.


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## Sandog

18G said:


> Great article!



Agreed, good stuff. I found it interesting (In first listed link) that when naloxone is used to treat fentanyl induced truncal muscle rigidity that deleterious side effects can occur in certain patients. 

I will also add to the link pool.

http://jms1.ndmctsgh.edu.tw/PDF/100202.pdf


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## Fish

Linuss said:


> Yeah, I'd be lying if I said I did it over 1-2 minutes, but I didn't slam it either.  Guess 50mcg over 30+ seconds still isn't slow enough.
> 
> But hey, I DO need an intubation



Do you bolus or give a little at a time with a bag hanging?


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## 18G

How about diluting it in 5-10mL's? Drug guide also says to give it over 2-3mins IVP. It seems the rate of admin is closely related.


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## WTEngel

I have found it more common in peds than adults. I have seen more than a few adult ERs administering fentanyl too fast and the patient ends up buying a tube. The patient that do develop the rigidity tend to go downhill fast.

It is hit or miss though. It seems like (in my experience anyway) the patients that have a tendency to develop rigidity, tend to develop it no matter what speed the med is pushed at (slower is obviously better, don't get me wrong.) These patients just have that sensitivity. The other segment of patients are typically ok, whether it is given over 30 seconds or 5 minutes.

Like I said earlier, the slower you push it the better. 1-2 minutes is good, with closer to 2 minutes being better...in my experience.

Watch yourself though, especially with peds. Luckily this time the outcome was ok, and you gained a valuable little bit of experience to put in your toolbox.


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## Ridryder911

Used to be called _stone chest syndrome_, one of the side effects usally caused by administering improperly -dosage or too fast. 

R/r 911


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## Epi-do

Ridryder911 said:


> Used to be called _stone chest syndrome_, one of the side effects usally caused by administering improperly -dosage or too fast.
> 
> R/r 911



OMG!!!  You are still alive!  Hope life is treating you well.  It's good to "see" you again.

And now, back to the scheduled programming.....

I have never personally seen a pt develop chest wall rigidity, but did have a doc in CCU talking about it with a med student.  I was still in medic class and was watching a procedure they were doing.  The doc was great and took his time to answer both my questions & the med student's questions about it.  It was definitely a learning opportunity that most in my medic class didn't get, and resulted in a great discussion about the topic in our next class.


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## SoggyToes

Would narcan reverse this side effect?


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## Smash

SoggyToes said:


> Would narcan reverse this side effect?



It seems to, but then you have an unpleasant situation for the patient that you were trying to fix in the first place.


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## ah2388

id never heard of this side effect, i suppose ill start paying extra special attention to my rate of administration for fentanyl


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## 18G

During my Medic clinicals my ED RN preceptor told me about this effect of fentanyl. She was relating her experience from working in a NICU and relayed this was more common in peds. She was a great preceptor.


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## Sam Adams

Just out of curiosity, does anyone palpate your pt's thorax prior to administration? You know, to get a baseline for when/ if it happens?


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## 18G

I had a 28y/o w/ a spleen lac. who was losing a lot of blood the other day. We were transferring him from our local ED to the trauma center by ground since heli couldn't fly due to weather. 

Pt. was in a lot of pain and I gave Fentanyl. I remembered this thread and pushed it (100mcg) over a full 1-2mins.... no problems with rigidity. 

On a side note.... if a pt. gets no relief with 50mcg, why would a hospital keep giving 50mcg doses when it's clear it's not touching the patients pain? Nothing like expecting change by doing the same thing over and over.


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## WTEngel

Depends on the amount of time between dosages. 50 mcg every 20 minutes without relief is a bit ridiculous, but 50 mcg every 3-5 until relief is noted doesn't sound too out of line. 

A lot of referrals I have been to seem to go one way or the other. They either are worried about too much pain medication, and the patient is coming unglued, or they go the complete opposite and the patient is breathing 5 times a minute with a pressure of "crap / crap" and a MAP of "please help me!" (this was quoted from one of my favorite nurses during an M&M meeting.)


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## 18G

These 50mcg doses were 30mins to an hour or longer in between. I gave 100mcg just a few mins out and the trauma doc ordered another 50mcg soon as we got to the trauma bay. Pt. was showing a trend with lowering of the B/P so was cautious about giving pain med. 

Pressure started at 120/70's and slowly dropped to SBP of 101 throughout the transport. MC advised to hold off on pain med until pressure improved with fluids... I wasn't thrilled about raising the pressure and wanted to maintain it right where it was with a close eye but did give fluid through a second line to achieve pressure of 114 at which time I gave pain med.


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## Sandog

> On a side note.... if a pt. gets no relief with 50mcg, why would a hospital keep giving 50mcg doses when it's clear it's not touching the patients pain? Nothing like expecting change by doing the same thing over and over.



Isn't that the definition of insanity?


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## helimedic39

I'm sure everyone knows this about Fentanyl, but it is a BP neutral med. Yes there are times when the BP drops, but it's usually in conjunction with another med or underlying problem. I read in an earlier post about the use of Narcan. Yes this will reverse the issue. My recommendation though is low dose. I've seen too many times people pull out the prefill 2mg and give this. Not necessary as 0.4 will suffice. I also like to dilute any narc in with 8 or 9 cc of saline depending on how much of the med there is. I have found that this does not give patients that "punch" of the med and its just easier to control when pushing rather than 1 cc. Just my 2 cents.


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## Sandog

One must exercise caution when giving Narcan to counteract Fentanyl, Hypertensive patients can go south.


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## usalsfyre

Usually it's not the fentanyl that causes a B/P dump, it's the midazolam. As far as small reductions in B/P, it's related to reducing pain and it's associated effects. Reversing fent with narcan shouldn't cause ANY change in B/P, other than the fact they're now going to start hurting agiain.


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## usalsfyre

18G said:


> These 50mcg doses were 30mins to an hour or longer in between. I gave 100mcg just a few mins out and the trauma doc ordered another 50mcg soon as we got to the trauma bay. Pt. was showing a trend with lowering of the B/P so was cautious about giving pain med.
> 
> Pressure started at 120/70's and slowly dropped to SBP of 101 throughout the transport. MC advised to hold off on pain med until pressure improved with fluids... I wasn't thrilled about raising the pressure and wanted to maintain it right where it was with a close eye but did give fluid through a second line to achieve pressure of 114 at which time I gave pain med.



This is just idiotic, and a doc that's not familiar with fentanyl.


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## usalsfyre

WTEngel said:


> ...or they go the complete opposite and the patient is breathing 5 times a minute with a pressure of "crap / crap" and a MAP of "please help me!" (this was quoted from one of my favorite nurses during an M&M meeting.)



Seen some of this with morphine. Usually though, it's the first example you gave. "The recieving needs to be able to assess them" battlecry :glare:.


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## jrm818

usalsfyre said:


> Usually it's not the fentanyl that causes a B/P dump, it's the midazolam. As far as small reductions in B/P, it's related to reducing pain and it's associated effects. Reversing fent with narcan shouldn't cause ANY change in B/P, other than the fact they're now going to start hurting agiain.



There are some old (70's and 80's) case reports and very tiny studies that apparently (no full text online that old, so going on abstracts alone) demonstrated a linkage between narcan administration and development of acute hypertension in patients with a baseline level of chronic hypertension.

Unfortunately I can't find any more modern update on the issue.  I wouldn't be surprised if most of the effect was due to unmasking of pain and reversal of opioid sympatholysis, however.


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## Sam Adams

jrm818 said:


> opioid sympatholysis



that's a mouthfull!


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