Pediatrics

Malignant Hyperthermia

Diagnosis

Hypermetabolism:

  • ↑ Temperature
  • ↑ HR
  • ↑ CO2
  • Acidosis

Diagnosis

Hypermetabolism:

  • ↑ Temperature
  • ↑ HR
  • ↑ CO2
  • Acidosis

  1. MH Hotline 1-800-644-9737

    Get MH Cart, dantrolene, and help

    • 2.5 mg/kg IV, q5 min as needed
    • Dantrium/Revonto: Assign dedicated person to mix 20 mg vial with 60 mL non-bacteriostatic sterile water
    • Ryanodex: 250 mg mixed with 5 mL non-bacteriostatic sterile water

  2. Inform surgeon and stop procedure, if possible

  3. Stop volatile anesthetic, succinylcholine.

  4. Attach charcoal filter. Turn O2 flow to 10 L/min

  5. Hyperventilate patient to reduce EtCO2

  6. Give dantrolene 2.5 mg/kg IV, rapidly, through large bore IV if possible, every 5 min until symptoms resolve. May need up to 10 mg/kg (if no response at this dose, consider DDx). May have one of two formulations at your hospital:

    • Dantrium/Revonto: Assign dedicated person to mix 20 mg vial with 60 mL non-bacteriostatic sterile water
    • Ryanodex: 250 mg mixed with 5 mL non-bacteriostatic sterile water
    • 2.5 mg/kg IV, q5 min as needed
    • Dantrium/Revonto: Assign dedicated person to mix 20 mg vial with 60 mL non-bacteriostatic sterile water
    • Ryanodex: 250 mg mixed with 5 mL non-bacteriostatic sterile water

  7. Transition to non‐triggering anesthetic

  8. Give sodium bicarbonate 1-2 mEq/kg IV for suspected metabolic acidosis

    • 1-2 mEq/kg IV

  9. Cool patient:

    • Apply ice externally to axilla, groin and around head
    • Infuse cold saline intravenously
    • NG and open body cavity lavage with cold water
    • Stop cooling when temperature < 38° C

  10. Hyperkalemia treatment:

    • Calcium gluconate 30 mg/kg IV or calcium chloride 10 mg/kg IV;
    • Sodium bicarbonate 1-2 mEq/kg IV;
    • Regular insulin 0.1 units/kg IV (MAX 10 units) and dextrose 0.5-1 g/kg
    • 1-2 mEq/kg IV
    • 30 mg/kg IV
    • 10 mg/kg IV
    • 0.1 units/kg IV, MAX 10 units
    • 0.5-1 g/kg

  11. VT or afib treatment: Do NOT use calcium channel blocker; give amiodarone 5 mg/kg

  12. Send labs: ABG or VBG, electrolytes, serum CK, serum/urine myoglobin, coagulation

  13. Place urinary catheter, maintain UO > 2 ml/kg/hr

  14. If cardiac arrest occurs, begin CPR & consider ECMO, go to CARDIAC ARREST

  15. If no response after 10 mg/kg dantrolene, consider DDx

    • 2.5 mg/kg IV, q5 min as needed
    • Dantrium/Revonto: Assign dedicated person to mix 20 mg vial with 60 mL non-bacteriostatic sterile water
    • Ryanodex: 250 mg mixed with 5 mL non-bacteriostatic sterile water

  16. Call ICU to arrange disposition. For post-acute management, see http://www.mhaus.org

  17. Crisis Management (If Severe)

    Notify surgeon, call for help and code cart

  18. Call for Transesophageal Echocardiography

  19. Start chest compressions

  20. Give epinephrine 10 MICROgrams/kg IV/IO

  21. If cardiac arrest, go to CARDIAC ARREST

  22. Consider ECMO

Patient weight

Between 0.5 kg and 120 kg

Reset the checklist?

Checked steps, the timer and this crisis log are cleared. The patient’s weight is kept.

Finish the crisis?

The timer pauses, and you can review the case and the event log.