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You are caring for a 10-year-old boy who was hit by an automobile. Due to a waxing and waning mental status, he is intubated with rapid sequence induction using etomidate and succinylcholine, followed by a fentanyl drip for post-intubation sedation. After returning from the CT scanner, the respiratory therapist tells you that he is “biting down on the tube.” On assessment you find that he is warm to the touch and tachycardic. His temperature is measured at 104.2 F, and his ETCO2 has risen to 58.
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July 21, 2025 at 8:43 pm
B) Anesthesiologist
The patient is exhibiting signs of malignant hyperthermia (MH) after succinylcholine administration. Classic signs include hypercarbia despite adequate minute ventilation, masseter muscle rigidity and generalized muscle rigidity (although this is less common in young children), hyperthermia, arrhythmias (most commonly sinus tachycardia but also peaked T waves, QRS widening, and ventricular ectopy associated with hyperkalemia), and myoglobinuria. Immediate critical management is needed, and anesthesiologists are the most likely to be trained in MH management. OR’s should have a special MH cart containing the mainstay of therapy, dantrolene, as well as other therapies to treat hyperkalemia and metabolic acidosis. MH occurs in susceptible patients with genetic skeletal muscle receptor abnormalities, most commonly after being given a volatile anesthetic agent such as isoflurane, sevoflurane, etc, but has also occurred with succinylcholine administration. Although genetic, 90% of patients do not have a known positive family history for an MH event at the time of presentation.