Fentanyl and chest wall rigidity

Shishkabob

Shishkabob

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

Do you bolus or give a little at a time with a bag hanging?
 
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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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.
 
Used to be called stone chest syndrome, one of the side effects usally caused by administering improperly -dosage or too fast.

R/r 911
 
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
Click to expand...

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.
 
SoggyToes said:
Would narcan reverse this side effect?
Click to expand...

It seems to, but then you have an unpleasant situation for the patient that you were trying to fix in the first place.
 
id never heard of this side effect, i suppose ill start paying extra special attention to my rate of administration for fentanyl
 
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.
 
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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