instantaneous rigor

[blindsideflank]

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?

 

[VFlutter]

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

 

[blindsideflank]

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)

 

[mycrofft]

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?

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).

 

[Trailrider]

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

 

[AjCapri]

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?

 

[blindsideflank]

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?

 

[mycrofft]

Define "trismus"....

 

[DrankTheKoolaid]

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

 

[Mariemt]

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

 

[blindsideflank]

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.

 

[usalsfyre]

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?

 

[NomadicMedic]

My question is, why did you not cut?

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

 

[mycrofft]

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.

 

[Carlos Danger]

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.



ever seen it? thoughts?

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

 

[DesertMedic66]

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.

 

[chaz90]

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.

 

[DesertMedic66]

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.

 

[TheLocalMedic]

 

[d_miracle36]

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.