Wild Case today!!!!

Specialties CRNA

Published

I was heading out the door today and they were fixing (texas term :)) to start a simple procedure (ingrown toenail) on a teenager. So I decided to just go in and watch the case. The patient was a bit nervous and the MDA spent a good 10 minutes just explaining to the parents that everything was going to be just fine, but he also discussed the risks. To make a long story short, we were going to sleep the patient and just put a simple LMA in and create the best situation for the patient. So we give the patient Lido 100mg and then Prop 70mg (the patient was 60kg). Next thing we know the patient is rearing up in the bed curling their toes and almost decerabrating. The patient had a big-time seizure!!! We were beside ourselves, especially after we had given 2 of Versed prior to bringing the patient into the room. 3 docs discussed the case afterwards and decided that the patient either had a serious reaction to the lidocaine (which is still kind-of grasping straws with such a normal dose) or the patient has something going on in their head. Needless to say we cancelled the case, admitted the patient, and they are going to do a CT scan. Anyway, just wanted to let everyone know that just because you have a "simple" case, doesn't mean that it will always turn out that way. BTW, the patient eventually woke up and was just fine. The patient was very distraught about the situation and thought they had failed in some way. The patient was sobbing. Keep this patient in your prayers.

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Be careful SCHMEGGA. The HIPPA's have internet access and that girl may have a nurse in her family. You've given plenty of information for someone with the right connections to put a name to the case.

The information's good I just worry that this is the wrong venue for the discussion.

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There we go that should be much better. That should be generic enough.

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Scary..to say the least, when you least expect it, something goes wrong.

I may be missing something here, but, you were putting a person down for an ingrown toenail? What ever happened to a simple digital block and then doing the procedure?

bob

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I would love to know if the MD would be able to find out what caused such a reaction for the future of this patient. Where the parents at the bedside? How do they reacted?

Please keep us informed.

Sorry about my ignorance, I am not in the field yet, are seizures a side effect of Lidoicaine?

Well, I just read PDR Nurse's drug handbook (2002), and found the answer:

Side effects: CNS: ......twitching, "doom anxiety," convulsions, unconsciousness....

I just want to learn from those in the field already.

Yamile

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Hi. I'm curious, we're y'all going to remove the toenail? I ask this because a couple of years ago I had to keep going to the doctor for a recurring ingrown toenail, till finally they just decided to remove it. The doc gave me a local, and twisted and pulled that toenail out (I watched part of it). I only live less than five minutes away from the clinic, but by the time I got home, the numbness quickly wore off, and I had the absolute most excrutiating pain I have ever felt (and I have a high threshold for pain), that I was actually screaming out in pain. Then I got major chills and started shaking uncontrollably. My hubby called the clinic, and they said to give me some advil, but we both demanded something stronger, so they called in a prescription. The pain was so bad (it was my big toe), that I had to stay pretty much knocked out for almost two days. Needless to say, I never quite forgave that doctor, so I switched physicians. Sorry, I don't recall what any of the medication used was. So, were you all going to remove the toenail, and if so, how?

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Specializes in NICU, Infection Control.

My son had both big toes done w/digital blocks and one Valium. And me comforting him. I put my jacket over him w/the hood over his face and he went to sleep.

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Interesting case, here are my thoughts.

The problem here with a digital block is the ingrown toenail cuts off circulation, so the local can't get to the site of action. Result is a poor block.

So if you might end up converting to general anyway, why not just start out with a general. No need to intubate. I might have just face masked. At 60 kg this teen was near adult size. Maybe it was one of those "football player" shaped boys, good sized, making mask fit difficult. LMA an excellent choice in that scenario.

I question if it was a true siezure, would be interested to see what neuro says. I have been told by seasoned CRNAs that young, healthy teenagers will wake up exactly like you describe. It looks like posturing. As a student, these instructors would always allow the teen to wake up "on their own", meaning none of the ususal stimulation to encourage them. No prodding, name calling, shoulder shaking, etc. They said that would only lead to a rocky emergence. Even without the stimulation, young people often wake up swinging.

Did the trouble start when you did something stimulating to the patient? I wonder if the level of anesthesia was adequate. Using a LMA is still general anesthesia, so a full induction dose of propofol is appropriate, at least 2mg/kg. No, I wouldn't decrease it because of the midazolam, 2mg is a drop in the bucket for a young, healthy teen.

Thanks for sharing an interesting clinical case. Let us know any further developments you learn of.

loisane crna

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Anyway, just wanted to let everyone know that just because you have a "simple" case, doesn't mean that it will always turn out that way.

Great point! Never let your guard down, even on those 'simple' cases.

I may be missing something here, but, you were putting a person down for an ingrown toenail? What ever happened to a simple digital block and then doing the procedure?

Two contraindications to local/MAC: 1. Teenager. 2. Anxious. Teen + anxiety = poor local/MAC candidate. Local/MACs can often be more challenging than general anesthesia, IMHO.

I also agree with loisane, the induction dose of propofol was low. Pediatrics age 3-16 years have an increased induction dose of 2.5-3.5 mg/kg. So the stimulation of inserting an LMA in a teenager in a light plane of anesthesia may have been the cause of the adverse reaction. My experience is teens do weird things (just as they do when they are NOT under anesthesia ;)) and tend to wake up swinging. Plus if the toe was infected, the local anesthetic may not adequately numb the surgical site.

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"just because you have a "simple" case, doesn't mean that it will always turn out that way"

Excellent point Schmegga. just wondering, I know the dose of lido was OK, but wonder if rate of admin could have caused this.

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Update.

The teen in the case prefered to be "put to sleep." That was the main reason, patient preference takes precedence. Other reason for general was that this Dr. prefers generals. Just one of his things. Don't knock him for it though because he is an excellent surgeon. Anyway, after much discussion it is believed that the patient may have an AVM (arterio-venous malformation). Therefore the lidocaine went through the venous circulation and crossed over to the artery and straight to the brain, which caused the seizure.

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Specializes in ER.

Wow.

I wonder if people with AV malformations are more likely to become IV drug abusers? Is the high more intense when it goes straight to the brain, or are they more likely to die with the first injection of IV drugs?

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