A young woman awoke early one morning to her partner cutting
off her hair, which was followed by stabs to her left neck and her left flank
with scissors. She was subsequently held
captive by her partner until she escaped over 7 hours later when he fell
asleep. She arrived to our trauma bay
hemodynamically stable, protecting her airway, and in no acute distress. She was noted to have a small stab wound to
the posterior triangle of the left neck, as well a larger stab wound to the
left flank.
Her chest x-ray was negative for pneumothorax or
hemothorax. The work-up of her neck stab
wound was negative for injury, however a triple contrast CT abdomen/pelvis
revealed an obvious left diaphragm defect as well as a small associated splenic
laceration secondary to her left flank stab wound. She was consented for surgery to repair her
diaphragm. The patient denied any prior
medical or surgical history, however she did report heavy tobacco and alcohol
use for several years. She denied prior
history of asthma. At no point during
her preoperative work-up did she experience altered vital signs, oxygen
desaturation, or change in physical exam.
Once in the operating room, the patient received intravenous
propofol and rocuronium for induction of general anesthesia. She was initially able to be bag-mask
ventilated, although airway pressures were high. Despite direct visualization
of the endotracheal tube passing through the vocal cords on three sequential
attempts, the patient could not be ventilated through the endotracheal tube. She had no chest rise, absent bilateral breath
sounds, and absent end tidal carbon dioxide.
Shortly thereafter, her oxygen saturations began to drop precipitously.
What next?
Ockham’s Razor is the principle that among competing
hypotheses, the hypothesis with the fewest assumptions should be selected. Herein is an example of failure of this
principle. When a patient has undergone
acute penetrating trauma to both the neck and diaphragm, it is both reasonable
and safe to assume that a new or unrecognized complication of one of these
injuries is causing the emergent problem, particularly in a young and otherwise
healthy patient. Did I somehow miss a
tracheal injury on my work-up of the neck stab wound? Did the patient develop a pneumothorax that
was not initially present?
Hypothesis #1: Tension Pneumothorax
Bilateral decompressive needle thoracostomies were performed
on this patient. There was no perceived
rush of air, and the patient continued to deteriorate with inability to
ventilate.
Hypothesis #2: Insecure Airway
Despite the reassurance from our anesthesia colleagues that
the endotracheal tube was in fact in the trachea, we assumed that the patient
was in fact not intubated and required an emergent surgical airway. Emergent cricothyroidotomy was then
performed. Following exposure of and
incision through the cricothyroid membrane, we encountered an endotracheal tube
surprisingly, which disproved our hypothesis.
The endotracheal tube was exchanged out for a tracheostomy tube. At this point, the patient continued to be
hypoxic and could not be ventilated.
Hypothesis #3: Tension Pneumothorax with Ineffective
Needle Decompression
Given the patient’s morbidly obese habitus, the needles may
have not penetrated the pleura.
Therefore, bilateral chest tubes were inserted emergently, however there
was no evidence of large pneumothorax or hemothorax to explain the patient’s acute
decompensation. She remained hypoxic
without effective ventilation.
What now?
At this point, the patient received the bronchodilator
albuterol via her tracheostomy with mild improvement in her saturation but
still minimal apparent ventilation. Intravenous diphenhydramine (anti-histamine)
was administered. While a bronchoscope
was being secured, epinephrine was repeatedly injected through the tracheostomy
into the bronchial tree. Finally, end
tidal carbon dioxide was achieved consistently, her breath sounds improved, and
her oxygen saturation normalized. Subsequent
bronchoscopy demonstrated no mucus plug and no traumatic injury to the trachea
or main bronchial tree.
Acute Severe Bronchospasm due to Rocuronium
This case highlights the importance of differential
diagnosis in a patient experiencing acute ventilatory failure in spite of
emergent surgical action to secure the airway and decompress the pleural
space. None of our surgical
interventions stabilized the patient, however a well-known intervention for
acute bronchospasm did. This patient
experienced a highly acute and rapid anaphylactic reaction with severe
bronchospasm following induction of general anesthesia.
In the literature, rocuronium
has been rarely associated with profound anaphylaxis and bronchospasm. In 2000, Neal and colleagues reported a case
series of three patients who experienced anaphylaxis and bronchospasm following
induction of general anesthesia with rocuronium. After stabilization, all patients underwent
antigen sensitivity testing and were confirmed to have reactions to
rocuronium. In 2006, Kubitz et al.
reported a case of life-threatening anaphylactic reaction after administration
of rocuronium with severe bronchospasm during which mechanical ventilation was
nearly impossible. This patient’s
reaction was confirmed with intradermal antigen testing as well. In 2010, Miyazaki and colleagues reported two
similar cases, also confirmed with positive reactions to rocuronium on
intradermal testing.
The drugs we administer are not benign. This patient sustained penetrating
trauma. The injuries she sustained were
not acutely life threatening, however she did have a life threatening reaction
after induction of general anesthesia, presumably from rocuronium. We frequently encounter airway obstruction
and ventilatory failure in the setting of trauma that are corrected by acute
surgical intervention (such as cricothyroidotomy or needle/chest tube decompression). However, we are humbled by this incident of
acute severe bronchospasm following administration of medications used
routinely for the induction of general anesthesia.
Sources:
Kubitz JC, Krause T,
Dietz R, et al. Severe anaphylaxis from rocuronium. Anaesthesist. 2006; 55(11): 1169-71.
Miyazaki N, Akita M,
Ono Y, et al. Two cases of anaphylaxis after induction of general
anesthesia using rocuronium. Masui.
2010; 59(6): 719-20.
Neal SM, Manthri PR, Gadiyar V, et al. Histaminoid reactions
associated with rocuronium. Br J Anesth. 2000: 84(1): 108-11.
No comments:
Post a Comment