Jaw opening

[IceDoc]

Had a guy come into ER, stw L chest, unknown down time. Upon my arrival, pt in PEA with CPR in progress. ER docs say they can't open mouth and that they have given Sux. Not one to believe anybody, I try to open mouth myself and sure enough, can't get mouth open more than 1-2cm. He wasn't biting down (not much neurologic function at that time anyway), just couldn't get it open.

Any ideas why his jaw wouldn't open? Most of the near death patients I've stuck tubes in have had nicely floppy jaws. Like this guy---->

I suppose to make this post a little more interesting the newbies might want to consider the following: Believe it or not, ER docs were ventilating well through ambu bag. On examination, I think if I take a miller 2 I could probably maneuver around enough to get a tube in (did it once before in a guy with TMJ). What's your next airway management step? Hopefully by December the answer is obvious.

But seriously, any ideas why this jaw wouldn't open? (besides tmj )

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[militarymd]

 

[Gator05]

Blind nasal, no dice = fiberoptic nasal, no dice = cric if I really can't get anything in the mouth.

 

[powermd]

I'd just whip out the Bullard I keep strapped to my utility belt...

 

[zippy2u]

Look up masseter muscle rigidity and see if it fits the scenario. Why give any muscle relaxant if the guys in PEA?-- he's a priick hair from being boxed. You could ram a jackhammer down his throat and he ain't goin' to fight ya. I know..., academic center and one of those ER squirrels prolly pushed the sux. Regards ---Zip

 

[Bertelman]

Was he cold? Maybe he was in rigor!

 

[nimbus]

I'd just whip out the Bullard I keep strapped to my utility belt...

Agree. Bullard has worked very well for me in electives cases with minimal mouth opening. Only need 1-1.5 cm to get it in.

 

[Noyac]

Masseter Muscle spasm is possible but what about the PEA? I suspect that the sux never really got to the receptors. In other words the CPR was not very effective.

 

[Bougie]

Agree with Noyac. The sux was probably never circulated around. This happens all the time at my institution where medicine residents "run" the codes. They push epi or atropine (usually without a flush) then stop compressions and stare at the monitor for something magical to happen.

 

[IceDoc]

Masseter Muscle spasm is possible but what about the PEA? I suspect that the sux never really got to the receptors. In other words the CPR was not very effective.

As far as this case goes, the pt has a stw to the left chest and is in PEA therefore, as someone else on this forum puts it, the fastest way to his heart is a left thoracotomy. Yes, there are a number of methods of intubating as noted above, but most can take a while (unless lucky or particularly adept). A "blind" nasal would be difficult since the pt isn't taking spontaneous respirations. The remainder of the techniques I think are limited by time, and in our ER, equipment availability. This pt is about to have his chest cracked and heading to the OR, therefore, the fastest way to secure his airway is a cricothyrotomy.

Case ending: We think the PEA was hypovolemia (no tampenade); filled his heart with Red Cross juice and pressure came back nicely. Out of OR in 3 hours, pt transferred to floor more or less neurogically intact 2 days later (quite surprising to me considering he didn't object to the cric and thoracotomy in the ER).

Of course my question was really with WHY the jaw wouldn't open. I sure I won't ever know definitively, but I was just curious. The Sux probably didn't circulate very well, and I would doubt that it was masseter spasm due to the sux. When I walked in, I did think it was Rigor Mortis and we were working on a dead man; but that was wrong. I guess I'll have to work on my physical exam skills.

 

[meddog1]

The light wand is Da Bomb (just don't whip it outta some fanny pack... LOL!)