Trismus

[sleepless near seattle]

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.

 

[Jambi]

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.

 

[Jambi]

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

I bet Vene or others could offer some useful input.

 

[FLdoc2011]

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?

 

[Jambi]

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

 

[sleepless near seattle]

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

 

[sleepless near seattle]

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

 

[DrankTheKoolaid]

re

strike that, just re-read the order of events

 

[Jambi]

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.

 

[DrankTheKoolaid]

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

 

[sleepless near seattle]

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.

 

[sleepless near seattle]

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.

 

[sleepless near seattle]

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.

 

[fast65]

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.

 

[sleepless near seattle]

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.

 

[usalsfyre]

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?

 

[sleepless near seattle]

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.

 

[sleepless near seattle]

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.

 

[Jambi]

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?

 

[Veneficus]

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?