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Archive Staff & Patient Safety 2020

We Stopped an MH Crisis in Its Tracks

Quick thinking and a well-trained staff allowed us to identify and prevent a malignant hyperthermia event in just nine minutes.

Carlos Moreno

Carlos Moreno, MD, PhD, DESA

BIO

GETTING PREPPED
All photos by Carlos A. Ibarra Moreno, MD, PhD, DESA
GETTING PREPPED The entire surgical team at Toronto General Hospital readies dantrolene for administration.

You never know how your staff will respond to a rare but potentially deadly malignant hyperthermia (MH) event until it actually occurs. When we found ourselves facing a recent crisis, our staff stepped up in a major way — and what we learned from the incident could help your team's response efforts if they ever wind up in a similar situation.

Like many MH emergencies, there weren't any early warning signs. From all outward appearances, the patient was the ideal candidate to anesthetize. At 22 years old, he was about to undergo surgery to remove a malignant scalp tumor. He was otherwise healthy, did not take any medications and had no allergies. It took about 45 minutes from the induction of anesthesia to get the patient positioned and ready for surgery.

Then it happened.

Just before the initial skin incision was made, the patient started to develop seizure-like movements. His muscles became rigid, his heart rate increased suddenly from 70 to 120 beats per minute and end tidal carbon dioxide quickly rose from 35 mmHg to 70 mmHg. The anesthesia fellow noticed the early warning signs of MH and informed the staff anesthesiologist, who was also present in the room. The staff anesthesiologist in turn confirmed the onset of MH and immediately started the treatment protocol for which our staff had been trained.

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