Case Study July 19

Case Study
Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from
behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to
stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.
Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic
surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the
best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the
emergency department just moments after the ambulance and are available to give permission for the operative
procedure.
As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems;
Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no
previous exposure to anesthesia.
Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg
wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for
laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.
After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the
PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the
patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30
minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis
and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour.
Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.
Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development
of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene,
antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing
cardiac rhythm.
The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another
episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to
the ICU, where he remains for 72 hours.
Case Study Discussion

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-
developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for
anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This
devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during
the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the
rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the
first person to note the rise in body temperature was the rescuer performing chest compressions.
The patient was managed appropriately. The staff was required to perform a number of actions to save this
patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood
laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with
the resuscitation was instrumental in providing the additional hands and expertise needed in this case.
Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat
dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac
arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of
occurrence. Fortunately, the patient was young and healthy and responded to the treatment.
Long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did
not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture
stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the
patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant
hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to
ensure patient stability throughout the procedure.
*Comminuted Fractures - A comminuted fracture is a break or splinter of the bone into more than
two fragments. Since considerable force and energy is required to fragment bone,fractures of this
degree occur after high-impact trauma such as in vehicular accidents.

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