Tremors Post Paralysis

[bgcornel]

Sorry to post this here, can't post anywhere else, please share your thoughts. Thanks
OK sedation and anesthesia question. We had a 50ish year old male come in hypertensive, 250/120, non-compliant with medications for about a week. History of Asthma and HTN. Received 20mg Labetolol in the ED, grasped his chest and went into PEA. Received an Atropine and 2 Epi’s with ROSC. He came up to the unit on Nipride and Cardene for his pressure. Was able to titrate the Nipride off without a problem. Remained extremely combative inspite of the propofol gtt he was on. Added an Ativan bolus and gtt to the cocktail without any change. We then got the Urine tox. report back and found him positive for Cocaine, Heroin, Meth and THC, happy 4th. So after getting up to like 10mg/hr on the Ativan and 60mcg/kg/min on the Propofol he got a Norcuron bolus and weight based drip which took care of the problem. The next day the ativan and norcuron had been discontinued and he kept having these tremors, almost like a shiver. The pulmonary/critical care doc said it was a result of the paralysis but my personal feelings were some sort of heroin withdraw. Anyone have any thoughts on this? By the way his BAC was negative last 3 admissions. Fairly frequent flier, 100+ admission in the last 5 years, not including countless ED visits.

[etherdome]

The Vecuronium wearing off would not cause an all over body "shiver" that I am aware of. During the hour or two that it takes to wear off the patients movements may seem jerky until it is completely gone but as far as total body shivering....it's not something I have ever seen or heard of. Not saying it couldn't happen but I just don't think so. Sounds to me like fear, fever, withdrawal, or baseline.

[ethernaut]

cocaine, heroin and meth all could cause similar symptoms... however, unless heroin has not been given/taken for a few days, you won't usually see such symptoms.. cocaine and meth can be a possibility.. remember, too, that if someone comes in to the ER with a cocaine toxicity and said hypertension, it is NOT recommended to give drugs like labetalol to bring down the BP. this will only worsen the strain on the heart and all that goes with it. what you typically want to give is an alpha andrenergic antagonist, like phentolamine or the like, because cocaine toxicity is an alpha mediated vasoconstriction, not beta. benzos work well usually too...
anyway, my guess would be tremors r/t drug screen, not muscle relaxants

[NursePink]

Agreed. Paralysis wear off resembles more like a 'fish out of water' jerking. From what I could find... seems that Clonidine would have worked nicely to not only treat the HTN but also supress the heroin withdrawal.

The withdrawal syndrome we have been discussing is what is termed 'primary' or 'early' abstinence. A substantial portion of the physical symptoms of this stage seem to depend on the activity of a part of the brainstem called the locus coeruleus. Opiates depress this area and it would therefore be expected to become hyperactive during withdrawal. The locus coeruleus is an important center in the brain's fear-alarm system, and such hyperactivity would be consistent with the marked anxiety and agitation withdrawing addicts report.

Precedex works on the locus coeruleus as well, but wouldn't have as much of an effect on the BP.

Even after living in FL for 8 years, I have very little experience w/ heroin addicts. Will be interesting to read others' perspectives on this.

Thanks for the scenario.

[armygas]

the locus coeruleus

AKA "the blue spot" :)