Make Malignant Hyperthermia Training Memorable

Creating an MH escape room is an alternative teaching style that will capture the attention of your staff. There are any number of questions about MH you can use to create an escape room scenario, but here are five to get you started based on information found on the website of the Malignant Hyperthermia Association of the United States (mhaus.org).

— Danielle Bouchat-Friedman

1. What are the last four digits of the MHAUS hotline?
a. 3797 c. 9797
b. 9737 d. 3737

Answer: b
The complete hotline number is 800-644-9737. MHAUS experts are board certified anesthesiologists with special expertise in MH and proper ways to manage a crisis. They man the line 24 hours a day to provide surgical teams with real-time advice on how to stabilize stricken patients. Post the hotline number on your MH cart and make sure it's easily visible for quick reference during an emergency. Be sure phones in ORs have access to an outside line, so a staff member can reach an MHAUS expert and direct the surgical team through response efforts.

2. What are the early signs and symptoms of malignant hyperthermia?
a. decreasing ETCO₂; bradycardia; muscle rigidity; tachypnea; hypoxia
b. rising ETCO₂; bradycardia; muscle rigidity; tachypnea; hypoxemia
c. rising ETCO₂; tachycardia; muscle rigidity; tachypnea; hypoxemia

Answer: c
An increase in a patient's ETCO₂, a decrease in arterial oxygen and tachycardia are often the first signs of MH. Other symptoms to be aware of are muscle rigidity, hyperkalemia and temperature elevation. A rise in temperature is often the last sign of MH, when treatment of MH has already started. As soon as early symptoms are noticed, stop administration of volatile anesthetics. Insert activated charcoal filters into the inspiratory and expiratory limbs of the breathing circuit and hyperventilate the patient with 100% oxygen at flows of 10L/min to flush volatile anesthetics. Bring the MH cart to the OR and start reconstituting dantrolene to prepare syringes that will be administered through the patient's peripheral IV line.

3. What is the initial loading dose of dantrolene needed to stabilize patients?
a. 2.5 mg/kg b. 5 mg/kg c. 10 mg/kg

Answer: a
Dantrolene, which directly interferes with muscle contraction to decrease calcium build-up in muscle cells, is the only specific treatment for MH. Administer 2.5 mg/kg of dantrolene rapidly through an IV based on the patient's total body weight, with as much as 10 mg/kg needed for treatment of heavier patients weighing approximately 100 kg to 150 kg. Repeat until the patient responds with a decrease in ETCO2, decreased muscle rigidity and/or lowered heart rate. Large doses (>10 mg/kg) may be required for patients with persistent contractures or rigidity.

4. How much sterile water is needed to reconstitute each available version of dantrolene: Revonto from US World Meds, Dantrium from Par Pharmaceuticals and Ryanodex from Eagle Pharmaceuticals?
a. 50 ml, 10 ml and 50 ml
b. 60 ml, 60 ml and 5 ml
c. 60 ml of sterile water for all three

Answer: b
Revonto and Dantrium are packaged in 20 mg vials, which are reconstituted for injection by adding 60 ml of sterile water and shaking until the solutions are clear. Ryanodex comes in 250-mg vials, which are reconstituted with 5 ml of sterile water and shaken to ensure the solution is an orange-colored, opaque suspension. Thirty-six vials of Revonto and Dantrium and three vials of Ryanodex should be stocked to administer the initial dose.

5. How quickly should dantrolene be administered?
a. within 15 minutes
b. within 10 minutes
c. within 4 minutes

Answer: b
Dantrolene should be available for administration within 10 minutes of the decision to treat for MH, and be available for all anesthetizing locations where MH trigger agents are used. This is a slight modification of the recommendation that the drug must be administered within five minutes, which was not made based on consensus discussion. Having staff use vials of expired dantrolene to practice reconstituting the drug is an effective way to ensure they're ready to respond as quickly as possible during a real-life event. Additionally, task cards are a simple and effective way to delegate responsibilities during an emergency response and ensure responding staff members know who's assigned to begin reconstituting the dantrolene.