Trismus

Did you catch the link to the case study I linked?

Yes, read the article. Very similar on many counts and does lend itself to the idea that the succs didn't help, but also the succs wasn't the cause of the trismus either, it was already present.
 
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?

Yes trismus prior to succs. Yes coffee ground emesis that eventually just turned to brown fluid with out much "coffee grounds". Curiously did NOT see the "chicken pox" or anything similar anywhere on the body. Though pt was on Rx for it (Valtrex and vicodin prn).
 
Ah, a non-sudden arrest.

OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?

I saw very similar picture in a pt who OD'ed on a handful of various meds including psych and pain meds. I can imagine also a localized central CVA causing that combination of effects without unilaterality. (Boy did spellcheck hate THAT one!).
"SHINGLES" may equal
RedHerring.jpg
 
Ah, a non-sudden arrest.

OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?

I saw very similar picture in a pt who OD'ed on a handful of various meds including psych and pain meds. I can imagine also a localized central CVA causing that combination of effects without unilaterality. (Boy did spellcheck hate THAT one!).
"SHINGLES" may equal
RedHerring.jpg

Temporal arteritis is sometimes misdiagnosed as shingles.
 
Ah, a non-sudden arrest.

OK, try putting the shingles on hold. What else, not inconsistent with the pt's other conditions such as Rx and OTC MEDS, age, or whatnot, could cause trismus, brady, then asystole?

I saw very similar picture in a pt who OD'ed on a handful of various meds including psych and pain meds. I can imagine also a localized central CVA causing that combination of effects without unilaterality. (Boy did spellcheck hate THAT one!).
"SHINGLES" may equal
RedHerring.jpg

Not sure if your replying to me or Vene. The shingles really didn't concern me much, outside of the possibility that whatever her infection process was may have affected CNS and/or respiratory and therefore somehow blocked the effectiveness of the paralytic.
 
Just tossing more clams in the kettle, as it were.;)
BTW, temporal arteritis:

temporal-arteritis-1.jpg


and:

http://en.wikipedia.org/wiki/Giant-cell_arteritis

Very interesting. I can see where it could MAYBE be misdiagnosed due to serum crusts and I assume localized pain, but absence of a dermatomic outline and frank vesicles or the succession of stages to them (red, itchy/burny, vessiculation) should steer one to consider alternatives.

Thanks for this thread and replies, I'm learning something new! This is a really potentially horrendous disease.
 
Just tossing more clams in the kettle, as it were.;)
BTW, temporal arteritis:

temporal-arteritis-1.jpg


and:

http://en.wikipedia.org/wiki/Giant-cell_arteritis

Very interesting. I can see where it could MAYBE be misdiagnosed due to serum crusts and I assume localized pain, but absence of a dermatomic outline and frank vesicles or the succession of stages to them (red, itchy/burny, vessiculation) should steer one to consider alternatives.

Thanks for this thread and replies, I'm learning something new! This is a really potentially horrendous disease.

In the early stages around the eye and face it looks just like shingles.

Slightly swollen, red, and terribly painful.
 
Roger painful, shingles burns like fire and tender. Learning more.
OP, again thanks for this thread!
 
Sometimes in severe trauma and burns, there is mucous breakdown and subsequent upper GI bleed in the stomach.

Since this is inflammatory mediated, I can find no reason a medical cause of severe or systemic inflammation could not do the same.
 
Back to the red fish though. If you said "dropping BP, GI bleed" I'd be thinking gastric or esophageal vascular accident. What would account for trismus, cerebral hypoxia due to lost circulation?

As for cricothyrotomy, if air WAS going in past the teeth, and a true cric could not be established (to get past the blood etc in the upper airway), I don't see where a cric could have made much difference, unless debris was occluding airway through the teeth.

I wonder if the deceased had a positive rectal guaiac?

EDIT:
Intracranial necrotizing arteritis could give CVA like effects, while temporal arteritis could yield the "shingles" affect. Assuming the "shingles" wasn't a red herring.
 
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Not sure I'd put GCA (giant cell arteritits) high on my DDx here. Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills. She was already going hypotensive and with some propofol may have just bottomed out and coded from that.

Not sure how to explain the trismus... possibly seizure? Were her limbs/extremities rigid?

Just looking at some case reports of trismus with GCA, but doesn't seem to be that common, classically it's jaw claudication with chewing. And this just seems such an acute crash for that.

Was the IV working? Maybe the succs just didn't get circulated enough, she was already in shock and maybe even arrest at that point?
 
Not sure I'd put GCA (giant cell arteritits) high on my DDx here. Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills. She was already going hypotensive and with some propofol may have just bottomed out and coded from that.

Not sure how to explain the trismus... possibly seizure? Were her limbs/extremities rigid?

Just looking at some case reports of trismus with GCA, but doesn't seem to be that common, classically it's jaw claudication with chewing. And this just seems such an acute crash for that.

Was the IV working? Maybe the succs just didn't get circulated enough, she was already in shock and maybe even arrest at that point?

IV was good, wondered the same thing, withdrew, got good return and continued to flush, 1000mL bag in by the time we reached ER.
 
Wow, what a call, it has had me researching for the past hour or so, and something I'm going to bring up to my fellow medics and Docs.

My first thought was Tricyclic Antidepressant Toxicity, or some kind of OD. But the Trismus brought me there, not common, but that is where my mind went.

As i was reading your account, I agreed that the Succs should have been withheld due to the BP, and I would have tried a Nasal Tube, or surgical cric. if anything just to make sure I had a secured airway. Also, when the PT coded, I would have started going down that road with CPR and Epi. If anything, just to cover my butt.

If I were in your shoes during that call, I'm not sure I would have done anything differently, but sitting on my couch it is easy for me to run it.

You did what you could, when you could, that is all we can do.
 
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.

If you aren't able to get any O2 into the lungs at any point, then doing everything you can for the heart would have ended up being pointless, but if the ER doc was able to get an airway, then the patient may have had a chance if you kept the circulation going (but not a good chance). If you really want to sit up thinking the scenario over in your head, you could have given Atropine while brady but the patient was unstable and brady so you would have needed to move to pacing immediately. This would have hopefully kept you from entering the asystole algorithm in the first place. How effective would pacing a patient for 10 minutes be with no O2 being delivered? Depends on the venous reserve and other things, but the patient likely would have had unreversible brain damage from the hypoxia. All in all, you lost a patient which sucks, but personally I don't think you could have done anything different that would have saved them. Try not to lose sleep over it. We are only human and do the best we can.
 
Not sure I'd put GCA (giant cell arteritits) high on my DDx here.

It is unnaturaly high on my differential in people suspected of shingles because I seen the results when it is misdiagnosed. It is an easy mistake to make, especially from the epidemiology standpoint and many providers I have met don't even remember GCA is a disease or how it presents.

Of course hard to say with the details we have but common things being common I'd put money on possible opiate overdose with questionable history of taking a a bunch of pills. She was already going hypotensive and with some propofol may have just bottomed out and coded from that.

I agree, very hard to say, but if there was truly coffee ground emesis, then I would lean towards her taking a bunch of opioids for a very bad pain that wasn't going away. Aneurysm or the like.

Assuming no equipment or procedure failure, the clenched jaw has to be from a local calcium release or neuro trigger. It doesn't seem like tetanus.

Not sure how to explain the trismus... possibly seizure? Were her limbs/extremities rigid?.

This is what os getting me, I was searching for causes of masseter tetany outside of succs admin, but so far came up empty.

Just looking at some case reports of trismus with GCA, but doesn't seem to be that common, classically it's jaw claudication with chewing. And this just seems such an acute crash for that.

I was figuring the arteritis was diffuse and the trismus was secondary to the crash. I read a couple of case reports of it on OD as well. But I can find nothing on GI bleeding from acute opioid OD. Which leads me back to she was self medicating for something more severe and probably undiagnosed than shingles.

As I am sure you know more than me, as you are one of those medicine guys, shingles often presents when there is some other decompensation somewhere. :)

Was the IV working? Maybe the succs just didn't get circulated enough, she was already in shock and maybe even arrest at that point?

If she had a ruptured aneurysm or esophageal varices, then succs likely would never have circulated in any effective way.

If I recall correctly there was no mention of shocks or vfib in the original post, which fits with a bleed.
 
Very interesting. I certainly wish we had more information specifically regarding ALL medicines and any acute/chronic conditions.

While they mentioned the valtrex and shingles, etc was that everything? I cannot help but feel there is something missing which is quite significant.

Did she have a UTI? Was she taking anything for it?
Tetanus was a fleeting thought but ruled out quickly.
Could she have had a coincidental TMJ issue?

I am leaning towards a very simple answer for the trismus and suspect several unrelated events may have simply occurred closely together resulting in post death mass confusion.

Continue with the dissection as it has been quite informative and if you are able to get any follow up information from the pathologist that would be great to hear.

As for the airway issue, surgical cric would have been done early on. Not QB'ing you, just saying there would have been no hesitation but I back that with only personal experience of the services I used to work for--it was never taboo or frowned upon.
 
Remember House's Rule: Pt's Lie (or at least can be bad historians)

Yes trismus prior to succs. Yes coffee ground emesis that eventually just turned to brown fluid with out much "coffee grounds". Curiously did NOT see the "chicken pox" or anything similar anywhere on the body. Though pt was on Rx for it (Valtrex and vicodin prn).

"19:25 Pt in and out of consciousness BP 78/52, HR 72
19:28 BP 50/28, no further"

"Can suction the cheeks as they continue to fill with coffee ground emesis, but that's it" Decompensating, probably descending down the decomp curve at a very steep rate.

With head repositioned BVM breath goes in Airway patent enough, although disregrding aspiration for that moment



OK, stepping around shingles and unknown causes, just these say "big GI bleed, pt going downhill very rapidly". Was the pt taking NSAIDS?

Trismus? What pain meds was she getting, exactly? Were psych meds or antiseizure meds being given off-label for chronic pain relief? Was the pt self-dosing?

The sidetracks are fascinating, but we haven't gotten a firm set of possibilities for the trismus. Also, although in a pt with their bloody stomach contents mysteriously issuing (vomiting, or just slipping up the esoph?), what measures were needed for an airway with a pt whom a BVM was ventilating but had this pro-pharyngeal junk? Nasophryngeal suctioning as low suction? Slipping an old-fashioned thin suction catheter behind some molars and trying to do that? (And do either of those without causing gagging?).
 
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"19:25 Pt in and out of consciousness BP 78/52, HR 72
19:28 BP 50/28, no further"

"Can suction the cheeks as they continue to fill with coffee ground emesis, but that's it" Decompensating, probably descending down the decomp curve at a very steep rate.

With head repositioned BVM breath goes in Airway patent enough, although disregrding aspiration for that moment



OK, stepping around shingles and unknown causes, just these say "big GI bleed, pt going downhill very rapidly". Was the pt taking NSAIDS?

Trismus? What pain meds was she getting, exactly? Were psych meds or antiseizure meds being given off-label for chronic pain relief? Was the pt self-dosing?

The sidetracks are fascinating, but we haven't gotten a firm set of possibilities for the trismus. Also, although in a pt with their bloody stomach contents mysteriously issuing (vomiting, or just slipping up the esoph?), what measures were needed for an airway with a pt whom a BVM was ventilating but had this pro-pharyngeal junk? Nasophryngeal suctioning as low suction? Slipping an old-fashioned thin suction catheter behind some molars and trying to do that? (And do either of those without causing gagging?).

We did suction the npa with a 14 french and got a fairly sig return. For all others that keep raising the other meds/ other medical prob questions: I've relayed everything we were told, have already been wondering if she was self medicating with u/k meds and was assuming that night that there was something, maybe many things, going on besides the shingles (if THAT was even properly diagnosed) causing the GI bleed and respiratory arrest. Can only go by what we're told, but always have assumed there was more to the story. Again, I'm not losing sleep over this, really just wondering what kind of input others have. Lots of good ideas out there, I really appreciate the input. Please don't think that I feel like I did everything right, I really do appreciate everyone's ideas specifically about things I may have done differently or added/considered. I think that's what a site like this is all about, different perspectives to help us all learn and be more proficient and efficient in the future. Rest assured however, I still believe that nothing was going to change the outcome of this pt. I've only been a medic for a couple years but have been an EMT-I on the same crew for 10+ years and am very comfortable / pragmatic about pt outcomes. I knew very early in this call that there was going to be very little I could do to change her outcome, though I did & will always try everything I can anyway with hope that I'm wrong and that miracles can happen.
 
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