# instantaneous rigor



## blindsideflank (May 20, 2013)

Thought I'd share this because it was new to me and my partners (and the emerg doc)

30's male smoked some crack. friends called for a seizure. Pt talking, confused (seemingly postictal). Pt codes as he is transferred to stretcher.

5 mins of code and an attempt to intubate is thwarted by trismus/rigor mortis?!?! no room for a king airway, couldnt get the opa in but bagged well with 2 npa's. (didnt get to cric)

asystole btw...

hospital arrival and PEA. Dr tries succs. nothing. Nurses look at us like we have a several hour old body and roll their eyes. They continue to work the code and we leave.



well here it is (wiki link..)
http://en.wikipedia.org/wiki/Cadaveric_spasm

"Physiological Mechanism 

ATP is required to reuptake calcium into the sarcomere's sarcoplasmic reticulum (SR). When a muscle is relaxed, the myosin heads are returned to their "high energy" position, ready and waiting for a binding site on the actin filament to become available. Because there is no ATP available, previously released calcium ions cannot return to the SR. These leftover calcium ions move around inside the sarcomere and may eventually find their way to a binding site on the thin filament's regulatory protein. Since the myosin head is already ready to bind, no additional ATP expenditure is required and the sarcomere contracts.

When this process occurs on a larger scale, the stiffening associated with rigor mortis can occur. It mainly occurs during high ATP use. Sometimes, cadaveric spasms can be associated with erotic asphyxiation resulting in death"


ever seen it? thoughts?


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## VFlutter (May 20, 2013)

Was only the jaw locked or the whole body in rigor?


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## blindsideflank (May 20, 2013)

Only jaw and neck. His arm was nice and loose for an IV.
And definitely asystole (or possibly VERY fine v-fib), confirmed with leads (so not equiphasic)


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## mycrofft (May 20, 2013)

blindsideflank said:


> Thought I'd share this because it was new to me and my partners (and the emerg doc)
> 
> 30's male smoked some crack. friends called for a seizure. Pt talking, confused (seemingly postictal). Pt codes as he is transferred to stretcher.
> 
> ...



Saw it once, an inmate took a small handful of mixed pain and psych meds, announced he was high, then fell like a tree. Seizure-like activity not seen but did see saccadic eye movements then trismus (Bit off tip of Yankhauer we were using).


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## Trailrider (May 20, 2013)

Interesting read, I've never heard of crack doing that to a person.


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## AjCapri (May 21, 2013)

blindsideflank said:


> Only jaw and neck. His arm was nice and loose for an IV.
> And definitely asystole (or possibly VERY fine v-fib), confirmed with leads (so not equiphasic)



So it wasn't technically rigor, just a similar stiffening?


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## blindsideflank (May 21, 2013)

well i dont know if its the crack that does it. All the cases seem to be when the person is hypermetabolic. 
the most famous case seems to be a man that was shot in the head while attacking his wife with a knife. They had to pry the knife out of his hand.

as for being true rigor? The wiki article states... 
"Cadaveric spasm, also known as postmortem spasm, instantaneous rigor, cataleptic rigidity, or instantaneous rigidity, is a rare form of muscular stiffening that occurs at the moment of death, persists into the period of rigor mortis[1] and can be mistaken for rigor mortis. The cause is unknown, but is usually associated with violent deaths happening under extremely physical circumstances with intense emotion"


@mycrofft: was he pulseless when he was stiff?


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## mycrofft (May 23, 2013)

Define "trismus"....


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## DrankTheKoolaid (May 23, 2013)

When I did coroner's work many moons ago, there were quite a few books that talked of it. It's rare but not unheard of


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## Mariemt (May 23, 2013)

Possible brain bleed? I know brain damage can cause arching and severe stiffening


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## blindsideflank (May 23, 2013)

mycrofft said:


> Define "trismus"....



"a motor disturbance of the trigeminal nerve, especially spasm of the masticatory muscles, with difficulty in opening the mouth (lockjaw); a characteristic early symptom of tetanus."

"a firm closing of the jaw due to tonic spasm of the muscles of mastication from disease of the motor branch of the trigeminal nerve. It is usually associated with general tetanus. Also called lockjaw."

"a prolonged tonic spasm of the muscles of the jaw."

"spasms of the muscles of mastication resulting in the inability to open the oral cavity; often symptomatic of pericoronitis."

(i feel dirty that i hit up wiki so much)


@ corky: thats interesting that you have seen it in books, it was difficult for me to find. (obviously your books would be more advanced on these topics). 
Is this person as salvageable as any other code? My guess is that if his cells are depleted of atp (and have been in anaerobic metabolism for so long) and he is this acidotic that this person is toast.


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## usalsfyre (May 24, 2013)

Not terribly unusual (not exactly common either though). I've never seen it, but I know of several people who have.  My question is, why did you not cut?


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## NomadicMedic (May 24, 2013)

usalsfyre said:


> My question is, why did you not cut?



Second this. That's a perfect opportunity for a surgical airway.


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## mycrofft (May 24, 2013)

mycrofft said:


> Define "trismus"....



Then define "rigor mortis". 

_Progressive_ body-wide *POSTMORTEM* stiffening of muscles/joint is a pretty good summary.

TRISMUS is not post-mortem. It can hit pretty fast, unlike rigor mortis. It affects trigeminal nerve motor distribution.







*EDIT:* Apparently trismus is a possibility postmortem in some circumstances, but not the same strictly speaking as we mean when it happens while they are alive. It is still almost universally accompanied by other postmortem neuromuscular changes, in my experience.


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## Carlos Danger (May 24, 2013)

blindsideflank said:


> Thought I'd share this because it was new to me and my partners (and the emerg doc)
> 
> 30's male smoked some crack. friends called for a seizure. Pt talking, confused (seemingly postictal). Pt codes as he is transferred to stretcher.
> 
> ...



Masseter muscle spasm?

It can be triggered by many things, most notably succinylcholine and volatile anesthetics. 

Nothing that I've read on it gives a clear explanation of how or why it happens, but it seems to be a similar physiological process to malignant hyperthermia.

Dantrolene may have broken it. Some say large doses of non-depolarizers will, too. I've also read that local anesthetic infiltration will work.

Also, was he hyperthermic?

Could have been heatstroke, or malignant hyperthermia itself: Pubmed


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## DesertMedic66 (May 24, 2013)

usalsfyre said:


> Not terribly unusual (not exactly common either though). I've never seen it, but I know of several people who have.  My question is, why did you not cut?



Possibly not in the OPs scope for his area. We removed it from my county protocols due to the fact it was only being used 1-3 times per year in the whole county.


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## chaz90 (May 24, 2013)

DesertEMT66 said:


> Possibly not in the OPs scope for his area. We removed it from my county protocols due to the fact it was only being used 1-3 times per year in the whole county.



Sucks for those 1-3 people huh? No service that uses surgical crics (or any other invasive airway device) utilizes the skill frequently. I'd wager a guess that it's almost as infrequent as most cops ever having to fire their duty weapon. Many paramedics can go through their whole career without performing a field cric. That being said, I am a firm proponent of keeping it in our scope. This is one of the interventions we have that can be a life changing skill. Used when indicated, it can realistically make a life or death difference for the patients that need it.


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## DesertMedic66 (May 24, 2013)

chaz90 said:


> Sucks for those 1-3 people huh? No service that uses surgical crics (or any other invasive airway device) utilizes the skill frequently. I'd wager a guess that it's almost as infrequent as most cops ever having to fire their duty weapon. Many paramedics can go through their whole career without performing a field cric. That being said, I am a firm proponent of keeping it in our scope. This is one of the interventions we have that can be a life changing skill. Used when indicated, it can realistically make a life or death difference for the patients that need it.



I would agree with this in a system with a lot of training (such as yours). My system not soo much. Instead of training people to keep up on skills our medical director prefers to pull things from the scope. We don't carry dopamine, can't intubate patients under 14 years old, and only carry MS as our only option for pain management.


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## TheLocalMedic (May 25, 2013)




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## d_miracle36 (May 25, 2013)

I had a patient like this once but it remained after he was resuscitated. Thought that could have been a seizure but later found Cadaveric spasm's. I tried to explain to my director that I could not intubate because the patients mouth would not open. I was able to insert a king airway in shortly after though.


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## mycrofft (May 26, 2013)

d_miracle36 said:


> I had a patient like this once but it remained after he was resuscitated. Thought that could have been a seizure but later found Cadaveric spasm's. I tried to explain to my director that I could not intubate because the patients mouth would not open. I was able to insert a king airway in shortly after though.



Rhetorically: how can so-called cadaveric spasm be equated with (mistaken for) a seizure? 

OP's pt was in trismus then died. "Cadaveric spasm" may apply.


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## d_miracle36 (May 26, 2013)

mycrofft said:


> Rhetorically: how can so-called cadaveric spasm be equated with (mistaken for) a seizure?
> 
> OP's pt was in trismus then died. "Cadaveric spasm" may apply.



Immediately after the patient arrested he was clinched during that period and it remained after rosc. I equated the trimsus with the seizure because I did not know any other reason. After researching on the Internet cadaveric spasm seemed more feasible. I thought I said that before but I may not understand your rhetoric.


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## blindsideflank (May 27, 2013)

I don't want to say too much about the call in terms of specifics but we were actually backing up another ALS crew. We suggested a cric but the attendant was happy with npa's and bagging for our short transport. I disagree and it was brought up later 

And to someone above. There was no trismus prior to the code


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## mycrofft (May 27, 2013)

d_miracle36 said:


> Immediately after the patient arrested he was clinched during that period and it remained after rosc. I equated the trimsus with the seizure because I did not know any other reason. After researching on the Internet cadaveric spasm seemed more feasible. I thought I said that before but I may not understand your rhetoric.



You got it right. 

It was "rhetorical" because I figured you had it right but not quite sure and didn't want to seem to say you had it wrong.

They aren't equated, but sometimes related.


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## mycrofft (May 27, 2013)

blindsideflank said:


> I don't want to say too much about the call in terms of specifics but we were actually backing up another ALS crew. We suggested a cric but the attendant was happy with npa's and bagging for our short transport. I disagree and it was brought up later
> 
> And to someone above. There was no trismus prior to the code



I quote:

 " 5 mins of code and an attempt to intubate is thwarted by trismus/rigor mortis?!?!"..but bagged well with 2 npa's. 

So the trismus set in during resuscitation effort. Got it. Could be related to the drugs too, as someone mentioned above....

Cric unnecessary  if "bagging well", and by that I assume we are talking about no clinical signs of asphyxia, chest rises and falls, breath sounds bilat in lungs, maybe even (wince) good pulse oximetry. Without additional spit and blood and stuff, teeth aren't airtight either. Sounds like the field crew "done good". Any implication by ER folks can't be related to this unless they're just pissy.


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## jefftherealmccoy (Jun 1, 2013)

In this situation would a depolarizing agent such as Sux be useful?


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## Nattens (Jun 1, 2013)

jefftherealmccoy said:


> In this situation would a depolarizing agent such as Sux be useful?



Not a bad idea, i'd say a non-depol would be a better idea due to the competitive antagonism preventing AcH binding leading to the flaccidity.


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## mycrofft (Jun 1, 2013)

*" 'Maybe some sux. Maybe some potassium. Maybe some Max'. Sometimes, 'dead' is DEAD. Now, how about some nice MLT sandwiches? Hmmm?".​*


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## Carlos Danger (Jun 2, 2013)

jefftherealmccoy said:


> In this situation would a depolarizing agent such as Sux be useful?



No.


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## blindsideflank (Jun 3, 2013)

Doc tried sux and it did nothing. we also carry Roc, but im trying to wrap my head around it working and I don't believe there is any way either paralytic would work, (based on the theory of how this happens)


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## Handsome Robb (Jun 3, 2013)

Not an appropriate crich scenario, at all. Crichs are only indicated in a cannot oxygenate/cannot ventilate situation and you stated you were getting good compliance with the BVM and NPAs.

I had a suicide do this a ways back. Was flaccid when I dropped the OPA then totally rigid when I went back to pull the OPA and put in the king.


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## jefftherealmccoy (Jun 3, 2013)

According to the Wiki article it mostly happens to groups of muscles rather than a the whole body.  Any ideas why?


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## Handsome Robb (Jun 3, 2013)

jefftherealmccoy said:


> According to the Wiki article it mostly happens to groups of muscles rather than a the whole body.  Any ideas why?



Can't comment as to why but I will say in my case I briefly described above it was only his neck and jaw, nothing else.


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