Clinical Features:A 14 month old female was brought in by ambulance to a level one trauma center following a facial mauling by a family pit bull. Injuries sustained included a skull fracture, left ear avulsion, transection of... [ view full abstract ]
Clinical Features:
A 14 month old female was brought in by ambulance to a level one trauma center following a facial mauling by a family pit bull. Injuries sustained included a skull fracture, left ear avulsion, transection of the left facial nerve, eyelid laceration of the right upper and lower eyelid, and lip through and through laceration. The patient was immediately intubated using etomidate and succinylcholine on arrival and emergently brought to the operating room where she underwent irrigation and debridement of facial lacerations, exploration of the canalicular system on the right, repair of upper and lower lid lacerations, repair of facial lacerations and lip lacerations. Intraoperatively, patient was maintained under anesthesia with sevoflurane, a total of ketamine 10mg IV and fentanyl 100mcg IV, paralyzed with rocurronium and reversed with glycopyrrolate and neostigmine at the end of the case. Upon emergence, patient was noted to have extreme stiffness and rigidity of the arms and legs which was concerning for decerebrate posturing. Patient was transported from the OR directly to CT intubated, however imaging did not demonstrate any new overt bleeding. She was then transported to PICU intubated and was later extubated a day after surgery without any signs of neurological deficits. CT head and MRI brain were obtained without any radiologic evidence that would explain the posturing. Neurosurgery commented that the injuries sustained by the dog mauling was unlikely to account for the symptoms seen postoperatively and it was likely caused by medications administered during anesthesia.
Conclusions:
Medications used in general anesthesia are known to have caused dystonias, ankle clonus, Babinski reflex, and decerebrate posturing. Decerebrate posturing is associated with serious neurological pathology. It is characterized by tonic extension of the knees and elbows, internally rotated shoulders, flexed MP joints, and extended interphalangeal joints. Decerebrate posturing can be seen when there are lesions between the red nucleus of the brain and the reticulospinal and vestibulospinal tracts, allowing for unopposed extension of antigravity muscles. Dystonia can be interpreted as posturing as well, and is characterized by contractions in opposing flexor and extensor muscles. It is caused by hyperdopaminergic and hypodopaminergic states in the motor cortex. For instance, a lack of dopamine in the caudate and putamen in Parkinson’s disease is the cause of the movement sequela seen. Opiods have been shown in animal models to prevent the release of dopamine and cause symptoms similar to Parkinson’s disease. A case report cited ketamine as the source of dystonia in a 20 year old IV drug abuser and suggested that the mechanism may be increased central noradrenergic activity. Additional anesthetics used in pediatrics such as nitrous oxide and midazolam have been cited for causing dystonia. It is important for anesthesia providers to keep in mind the central effects of the medications we commonly use while providing an anesthetic. One consequence of these effects is posturing on emergence from anesthesia.
