Case summary:

An ALS crew responded to a 40s man who was found sitting on the toilet unresponsive.  When the crew arrived, they found the patient pulseless so they imitated CPR while getting additional information from the family.  Family informed the crew that he mentioned that his jaw was locking up making his shortness of breath worse.  He has a history of diabetes and the family reported that they witnessed the patient become unresponsive just before calling 911.  While doing CPR, the crew noted that the patients jaw was rigid, but the rest of his body was flaccid and there was no signs of dependent lividity.  Initial rhythm was asystole and crew gave epinephrine doses every 3-5 minutes throughout the arrest.  The crew was having trouble bagging the patient due to complete trismus and also noting that vomit was coming from the mouth.  The crew proceeded with surgical cricothyrotomy and were able to successful place the endotracheal tube surgically and confirmed placement with ETCO2.  After placing the surgical airway, the crew continued CPR and the patient remained in asystole.  After 7 total rounds of epinephrine and 35 minutes of CPR, the crew called medical control to discuss field termination of CPR.  Given meaningful recovery seemed very unlikely, online medical control pronounced the patient and further efforts were stopped.

Highlights of the case:

Trismus in cardiac arrest

Trismus is jaw rigidity and this finding in cardiac arrest can be very difficult.  The first thing we should do when we notice this is to consider if the cause is rigor since the presence of rigor means the patient has been in cardiac arrest for a while and should not be resuscitated.  These patients would be considered dead on arrival (DOA).  Rigor of the jaw can often be the first place that we notice rigor starting to occur.  At the same time, patients with a pulse can have trismus so it would not be recommended to use this finding alone to determine that a patient meets criteria for being DOA.  When the crew noticed the trismus, they quickly looked for other findings that could indicate that this was a DOA.  When they could not find any, they correctly assumed this was not rigor and continued resuscitation. 

The final stage of every difficult airway algorithm is surgical airway

Due to this patient’s trismus, the crew was unable to manage the airway with bag valve mask (BVM) or advanced airways such as supraglottic devices intubation with an endotracheal tube.  If the patient was not vomiting, it would have been reasonable to place bilateral nasopharyngeal airways and continue to manage the airway with BVM.  The crew correctly realized a surgical airway was indicated and successfully performed a surgical cricothyrotomy and confirmed placement with ETCO2.  Doing this gave this patient his best chance at survival.  While this patient ultimately expired, the crew provided top notch cardiac arrest care and was able to successfully manage a very difficult airway.