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Society of Rural Physicians of Canada26TH ANNUAL RURAL AND REMOTE MEDICINE COURSEST. JOHN'S NEWFOUNDLAND AND LABRADORAPRIL 12 - 14, 2018Dr. Gavin Parker PINCHER CREEK AB 140MALIGNANT HYPERTHERMIAMalignant hyperthermia is a rare and serious complication of providing a general anestheticor a potential reaction to medicines given in the rural ED. Using a case from a rural OR wewill discuss management of this case and how to avoid a similar outcome in your facility.1. Compare MH Physiology and epidemiology 2.Discuss Clinical manifestations 4.Differentialdiagnosis and treatment 5.Case review 6.MH resources

4/26/2018Gavin G. Parker, B.Sc., M.Sc. (Med. Ed.), M.D., C.C.F.P.(FPA)Rural Medicine and GP-AnesthesiaCommunity Medical Director - Pincher Creek Health CentreClinical Assistant Professor, University of Calgary11

4/26/2018 Physiology and epidemiology Clinical manifestations Differential diagnosis and treatment Case review MH resources3 Inherited disorder of skeletal muscle Problem w/ reuptake of intracellular Ca2 Exact cause uncertain Ryanodine receptor Disease inheritance is autosomal dominant42

4/26/2018 Definite association: central core disease Possible association: Duchenne, Becker,King-Denborough, other myopathies Coincidental association: neurolepticmalignant syndrome, SIDS, Lymphomas, andHeat Stroke5 Frequency 1:3,000 - 1:60,000 anestheticcases Approximately 600 cases per year in U.S1 Increased incidence in young adult males 1:100,000 hospital discharges complicatedby MH63

4/26/2018Muscle ContractureTest Caffeine HalothaneContractureTest(CHCT) Gold StandardGenetic Testing Ryanodine receptor(RYR1 Gene) Primary genetic focus DNA blood test orbiopsy MH Muscle BiopsyCenter7MH Triggers Potent volatileanesthetics SevofluraneDesfluraneIsoflurane Depolarizing musclerelaxants NOT MH Triggers Nitrous oxide IV induction agents Non-depolarizingmuscle relaxants OpioidsSuccinylcholine84

4/26/2018Specific Muscle rigidity* Increased CO2production Marked temperatureelevation RhabdomyolysisNon-Specific Tachycardia Tachypnea Acidosis (respiratory;metabolic) Hyperkalemia9 Insufficient anesthesiaor analgesia Insufficient ventilationor FGF Anaphylactic reaction Pheochromocytoma Cerebral ischemia Neuromusculardisorders Procedural causes Malignant neurolepticsyndrome Thyroid crisis105

4/26/2018 Stop triggering inhalationagents/succinylcholine Hyperventilate high flow 100% O2 Dantrolene 2.5mg/kg push, repeat prn Continue monitoring & interventions Treat hyperthermia, acidosis, andarrhythmias11 Muscle relaxant Indications The only specific and effective treatment for MH Neuroleptic malignant syndrome, muscle spasticity,serotonin syndrome, and 2,4-dinitrophenol poisoning Drug Interactions CCBs, NDNMB, CNS depressants & benzodiazepines126

4/26/2018 Shut down/disable vaporizers Flow O2 10L/min for 20 minutes throughmachine and ventilator Change CO2 absorbent Use non-trigger agents and methods Monitor for early signs of MH13 6 year old for dental surgery, no family history ofanesthetic issues Gas induction with sevoflurane, tube changedhalfway through case with succinylcholineassistance EtCO2 increased, never did get hyperthemic Eventually had muscle bx, confirmed spont. mut.147

4/26/2018 Site specific policy Malignant Hyperthermia Cart MHAUS Malignant Hyperthermia Association of theUnited States @ 1-800-MH-HYPER www.mhaus.org15 Disorder with intracellular Ca2 effectingskeletal muscle Triggered by inhaled anesthetics &succinylcholine Specific and non-specific clinical signs Definitive treatment with Dantrolene168

4/26/2018 Call for help (let surgeon know) Turn off potential triggering agents Administer dantrolene 2.5 mg/kg every fiveminutes Cool patient to 38C Monitor and correct blood gases, electrolytesand glucose17 Brady, J.E., Lena, S.S., Rosenberg, H., Li, G. (2009). Prevalance of malignanthyperthermia du to anesthesia in new york state, 2001-2005. Aneshtesia &Analgesia. 109:1162-1166. Glahn, K.P.E, Ellis, F.R., Halsall, P.J., Muller, C.R., Snoeck, M.M.J., Urwyler, A., &Wappler, F. (2010) Recognizing and managing a malignant hypthermia crisis:guidelines from the European Malignant Hyperthermia Group. British Journalof Anaesthesia. 105 (4):417-420. Rosenburg, H., Brandom, B.W., & Sambuughin, N. (2009). Malignant Hyperthermiaand Other Inherited Disorders. In P.G. Barash, B.F. Cullen, & R.K. Stoelting.(Eds.) Clinical Anesthesia (6th ed., pp. 598-619). Philadelphia: LippincottWilliams & Wilkins Stoelting, R., & Hiller, S. (2006). Handbook of Pharmacology & Physiology inAnesthetic Practice (2nd Ed). Philadelphia: Lippincott Williams & Wilkins Torpy, J., Lynm, C., Glass, R.M. (2005). Malignant Hyperthermia. JAMA; 293 (23):2958189

MALIGNANT HYPERTHERMIA Malignant hyperthermia is a rare and serious complication of providing a general anesthetic or a potential reaction to medicines given in the rural ED. Using a case from a rural OR we will discuss management of this case and how to avoid a similar outcome in your facility. 1.

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