From the OR to the ER: a case of MH

Reprinted with permission from Outpatient Surgery Magazine

Marsha Thornhill, MD, the director of anesthesia at the Teaneck (N.J.) Surgical Center, helped save an 18-year-old patient’s life 7 years ago. The patient was having a rhinoplasty at a 1-room office-based plastic surgery center.

The case was going very well, Dr. Thornhill remembers, but while the surgeon was closing, she noticed that the patient’s CO2 had increased from the 30 mmHg range to 50 or 60. “He was intubated, so it was a concern,” she says. Dr. Thornhill hyperventilated the patient to try to get his CO2 down, but it shot up into the 90s. She took him off mechanical ventilation and bagged him. Possibly fluid in the lungs, she thought, but his chest was clear and breath sounds were equal. She tried to suction the nasogastric tube, but it was patent.

Body temperature was normal. Less than a minute later she checked his temp again and it was 104°F. They stopped the surgery and began the malignant hyperthermia protocol that she and the surgical team had practiced over and over again at lunchtime. “You remove a level of anxiety, think more clearly and can focus on the best patient care when you eliminate ‘where is everything?’” says Dr. Thornhill.

Everyone had an assigned job. The head nurse called the MHAUS (Malignant Hyperthermia Association of the United States) hotline to let them know they had a case. Dr. Thornhill remembers MHAUS being a great resource, telling them that it’s normal to see stiffness in body and bluish-reddish mottling and blotching of the skin. “It was reassuring to know these things are normal.”

Another staff member packed the patient with ice. Another placed an IV line and another placed a Foley catheter through which they placed cold saline. Somebody took blood and urine samples. Another was in charge of recording what was happening.

Mixing dantrolene, perhaps the most important step in an MH episode, was a 2-person job. Dantrolene takes time and very vigorous shaking to liquefy. It simply doesn’t dissolve quickly in sterile water, says Dr. Thornhill. “You really need to shake it well — do whatever you can to get it to dissolve,” she says. “That’s something I think is really important to practice so you’re not wondering if you’re doing something wrong and you know how much time to allot.”

The surgeon had a job as well. He contacted the hospital that was going to receive the MH patient and gave the ER a full report. The ER used a cold blower to cool the room before the patient arrived. Dr. Thornhill and the head nurse rode with the patient in the ambulance. They took along a bucket of ice for the ambulance ride to keep the patient cool. They also brought with them an emergency transfer tackle box stocked with such items as vials of dantrolene, propofol, a muscle relaxant, an endotracheal tube, tape and an oral airway.

“The chances of a paramedic having seen MH in his career is probably very low,” says Dr. Thornhill. “You can almost be assured they don’t stock dantrolene in the ambulance, let alone know how to give it.”

The patient’s temperature returned to normal shortly after he arrived in the ER. Dr. Thornhill credits the mock drills. “It’s all about mock codes and practicing all those different scenarios so that you’re comfortable in an emergency,” she says.