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Zanaflex Capsules Package insert. Prescribing information. Acorda Therapeutics, 2006.
Because of trauma and associated pain, it is assumed that gastric emptying will be significantly delayed. To avoid pos-sible aspiration at the time of intubation, a very rapid-acting muscle relaxant should be used so the airway can be secured with an endotracheal tube. Usually, succinylcholine would be the agent of choice in this case; however, the patient has a ruptured (open) globe. Succinylcholine is contraindicated in patients with an open globe because it raises intraocular pressure and could possibly result in extrusion of aqueous or vitreous humor. Therefore, a rapid sequence intubation should be performed with high-dose (up to 1.2 mg/kg) rocuronium, a nondepolarizing muscle relaxant. At this dose, rocuronium has a very rapid onset, which approaches but does not quite equal that of succinylcholine. In the case vignette, you are unable to intubate the patient and may be unable to mask ventilate the patient. In this setting, use of the reversal agent sugammadex is indicated. Since a large dose of rocuronium was just given, a dose of 16 mg/kg of sugammadex needs to be given to rapidly and completely reverse the effects of the neuromuscular block-ing agent and allow return of spontaneous ventilation. In order to proceed with surgery, another technique (such as an awake fiberoptic-assisted intubation) should be used to secure the airway.
Pharmacologic Management of Parkinsonism & Other Movement Disorders
Michael J. Aminoff, MD, DSc, FRCP
A 76-year-old retired banker complains of a shuffling gait with occasional falls over the last year. He has developed a stooped posture, drags his left leg when walking, and is unsteady on turning. He remains independent in all activi-ties of daily living, but he has become more forgetful and occasionally sees his long-deceased father in his bedroom. Examination reveals hypomimia, hypophonia, a slight rest tremor of the right hand and chin, mild rigidity, and impaired rapid alternating movements in all limbs. Neuro-logic and general examinations are otherwise normal. What is the likely diagnosis and prognosis? The patient is started on a dopamine agonist, and the dose is gradually built up to the therapeutic range. Was this a good choice of medications? Six months later, the patient and his wife return for follow-up. It now becomes apparent that he is falling asleep at inappropriate times, such as at the dinner table, and when awake, he spends much of the time in arranging and rear-ranging the table cutlery or in picking at his clothes. To what is his condition due, and how should it be managed? Would you recommend surgical treatment?
Several types of abnormal movement are recognized. Tremor consists of a rhythmic oscillatory movement around a joint and is best characterized by its relation to activity. Tremor at rest is characteristic of parkinsonism, when it is often associated with rigidity and an impairment of voluntary activity. Tremor may occur during maintenance of sustained posture (postural tremor) or during movement (intention tremor). A conspicuous postural tremor is the cardinal feature of benign essential or familial tremor. Intention tremor occurs in patients with a lesion of the brainstem or cerebellum, especially when the superior cerebellar peduncle is involved; it may also occur as a manifestation of toxicity from alcohol or certain other drugs.