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Medical Cases Podcast

Medical Cases Podcast is a medical variety show whose target audience includes Internal Medicine and Emergency Medicine residents, medical students and foreign medical graduates. Podcasts will be 1 of 4 types: knowledge pearls (KP), clinical pearls (CP), board review (BR) and cases.
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Medical Cases Podcast - EM/IM/Critical Care

Aug 15, 2016

Episode #2

A knowledge pearl episode with a short case seen during intern year of residency. These three clinical entities all share a common theme; they develop quickly and need definitive management within minutes. 

 

Fentanyl rigid chest syndrome: chest wall/abdominal/masseter rigidity following the administration of fentanyl. More commonly seen with doses >4mcg/kg but can be with ANY dose. 

Risk factors: higher doses, fast push rate, extremities of age, critical illness and use of medications that alter dopamine levels.

Treatment:

  1. Double check your mask seal.
  2. Recognize what is going on.
  3. Give naloxone.
  4. If still unable to ventilate- paralyze with Succinylcholine. 

 

Succinylcholine masseter muscle rigidity (MMR): whereas mild masseter rigidity and jaw stiffness is common up to a minute after giving succinylcholine, MMR presents with severe prolonged jaw stiffness after giving sux. Some of these patients will progress to outright malignant hyperthermia (MH) and management should proceed accordingly. 

Risk factors: inadequate dosing of sux (<1mg/kg), children, myotonia congenita, duchenne muscular dystrophy. 

Treatment:

  1. Double check your ventilations
  2. Recognize what is going on.
  3. Consider propofol for further sedation.
  4. Administer a non-depolarizing agent such as rocuronium or vecuronium.
  5. Expectant management for MH - monitor vitals, EtCO2 (>55 mmHg is bad), urine, cpk, abg.
  6. Give dantrolene 2.5mg/kg if MH. 

 

Ketamine Induced Laryngospasm: laryngospasm seen after giving ketamine. Results in difficult ventilation. Can often be managed with CPAP or positive pressure ventilation using a BVM. 

Risk factors: children <3 mo, pts with active URTI or asthma, larger doses, rapid push rate. 

Treatment:

  1. Double check your mask seal
  2. Recognize what is going on/ call for help.
  3. Give 100% FiO2 through tight mask sealed BVM with positive pressure or CPAP.
  4. Attempt pressure at "Larson's Point" (may or may not work).
  5. Consider propofol for further sedation
  6. Give succinylcholine (4 mg/kg IM or 1.5 mg/kg IV) for paralysis - this is very rarely needed for isolated ketamine induced laryngospasm. Use Broselow tape to determine dosages in children. 

 

 

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