MH-susceptible patient with a mandible fracture26-year-old man, 80 kg; bilateral mandible fracture after an assault; listed for fixation with nasal intubation tonight

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 26-year-old with confirmed MH susceptibility, a full stomach and a mandible fracture, for urgent fixation. Patient
   • As an assault victim: head and neck injuries looked for; CT shows no base-of-skull fracture.
   • No volatile and no suxamethonium, even with dantrolene in the room. Disease
   • Full stomach and alcohol mean aspiration risk; nasal intubation suits the surgeon. Airway
   • His jaws will be fixed shut at the end; the airway after surgery is the danger. Surgery

2. Prepare

   How do you prepare?

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   • Clean machine: vaporisers removed, new absorbent and new circuit. Disease
   • Charcoal filters on the inspiratory and expiratory sides; after a flush-only prep, I never let flows drop below 10 L/min.
   • Dantrolene givable within 10 minutes; no dantrolene before surgery.
   • Core temperature probe and capnography from the very start.
   • Wire cutters taped to his bed; the surgeon shows recovery staff what to cut. Airway

3. Plan

   How do you secure his airway and run the case?

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   • Rapid sequence with propofol and rocuronium 1.2 mg/kg; no suxamethonium. Airway
   • Sugammadex 16 mg/kg ready for immediate reversal if intubation fails.
   • Nasal tube by videolaryngoscope; if the view is poor, I stay oral and the surgeon works around it.
   • Maintenance by TIVA, propofol at 100–200 mcg/kg/min plus a remifentanil infusion. Disease
   • Awake extubation: fully reversed, obeying, stomach aspirated. Airway
   • Usual recovery criteria; susceptibility alone doesn't need a long stay. After surgery

4. Crisis

   Ten minutes after extubation, with his jaws wired, he has stridor, rocking chest movements and SpO2 84%. What do you do?

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   • Airway obstruction behind wired jaws: call for help, 100% oxygen. Crisis
   • Cut the wires or bands now so I can open his mouth.
   • Suction, jaw thrust, nasal airway; sit him up. Airway
   • Still obstructed: Plan A, reintubate with propofol and rocuronium, never suxamethonium.
   • Plan A fails: supraglottic airway; if that fails, facemask ventilation.
   • Can't intubate, can't oxygenate: Plan D, an emergency surgical airway through the neck.

5. Crisis

   Forty minutes later in recovery: temperature 38.6 °C, HR 128, RR 26, sweating. What do you do?

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   • MH must be excluded, but fever is a late sign, not an early one. Crisis
   • Gas now: CO2, acidosis, potassium and CK; I feel for rigidity.
   • If he's hypermetabolic: dantrolene 2.5 mg/kg IV, repeated 5-minutely to a 10 mg/kg ceiling.
   • Other causes: aspiration or wound sepsis, thyroid crisis, recreational drugs, serotonin syndrome.
   • Cool him and support while results come back.
   • If MH: ICU, with dantrolene 1 mg/kg 6-hourly continued for 48–72 hours. After surgery