Medical History Of Asthma Research Articles

Masseter muscle rigidity after administration of succinylcholine during rapid sequence induction

Case Report A 79-year-old, 8Wlogram woman with a medical history of asthma, atria1 fibrillation, Type-I diabetes, congestive heart failure and hypertension, presented to an outlying emergency department complaining of shortness of breath. She had been seen two days earlier for similar complaints, which were diagnosed and treated as an exacerbation of her asthma. On the day of transfer, the patient arrived in florid pulmonary edema. This diagnosis was confirmed by physical exam and chest X-ray. Initial arterial blood gases (ABGs) showed a pH of 7.08, PaCOz of 73 torr, PaOz of 50 tot-r, and a bicarbonate of 21 mEq. The electrocardiogram demonstrated atria1 fibrillation with a ventricular rate of 120 and evidence of anteroseptal ischemia. Her initial treatment included 120 mg of intravenous furosemide, 3 mg of intravenous bumetanide and initiation of a nitroglycerine drip at 50 mcg/min. Ventilation was assisted with 100% oxygen via bag-valve-mask (BVM) device. Repeat ABGs, following this treatment, showed a pH of 7.29, PaC02 of 43 torr, PaOa of 98 torr and a bicarbonate of 20 mEq. Electrolytes were reported to be within normal limits. On arrival of the flight crew, this patient was ashen and diaphoretic. Ventilation was being assisted via BVM at a rate of 44 breaths/min. Rales were audible in all lung fields. The patient’s blood pressure was 132/96 mmHg, and her heart rate was 130 and irregular. Three attempts at nasotracheal intubation were unsuccessful. Therefore, rapid sequence induction for orotracheal intubation was undertaken. As per protocol, an initial 50 mcg dose of fentanyl citrate was followed by 120 mg of succinylcholine. These were given intravenously while cricoid pressure was applied. Flaccid paralysis of the extremities was obtained in approximately 40 seconds. Difficulty was encountered in attempting to insert the laryngoscope because of limited motility of this patient’s mandible, which effectively reduced her mouth opening to approximately 4 cm. This lack of motility initially was felt to be related to arthritic changes in the temporomandibular joint. Visualization of the epiglottis was achieved with difficulty, but the poor motility of the mandible rendered visualization of the vocal cords impossible. Multiple attempts at orotracheal intubation by two experienced providers were unsuccessful. Hyperventilation between intubation attempts with 100% oxygen via BVh4 enabled maintenance of oxygen saturation between 89% and 95%. Cricoid pressure was maintained throughout the periods of paralysis. Two