Rocuronium as Neuromuscular Blockade in Tetanus Patients With Methamphetamine Use Disorder: A Case Report

Abstract

Background: Spasm control is essential in the management of tetanus. Benzodiazepines are administered as initial treatment of tetanic spasms; however, sedation may be difficult to attain among patients with methamphetamine use disorder. Neuromuscular blocking agents, which act on an entire different mechanism, can be given to induce paralysis. Methods: We describe 2 cases of patients with methamphetamine use disorder who were diagnosed with severe tetanus and our experience in the use of rocuronium to control their spasms. We performed a systematic review of the SCOPUS and PubMed databases for case reports and case series describing the use of rocuronium in tetanus patients who also have methamphetamine use disorder. We discussed the clinical features and treatment outcomes. Results: A total of 4 cases of patients with substance abuse disorder who had severe tetanus were reported in the literature, including the current cases. The mean age was 28.8 years; all of them male. Trismus, generalized limb and abdominal rigidity were the most common presentation. Three patients underwent emergency tracheostomy. Rocuronium was given as 0.008mg/kg bolus in 1 patient; 2 patients received an intravenous bolus dose of 0.6mg/kg. Infusion dose ranged from 5 to 10 mcg/kg/min. Spasms were controlled within 24-48 hours after giving rocuronium in 3 out of 4 patients. One patient died from complications of dysautonomia and immobility. Conclusion: Rocuronium demonstrates a potential role as neuromuscular blocking agent of choice for patients with chronic methamphetamine use disorder and severe tetanus. Management challenges and complications of severe tetanus were also highlighted in this study.

Emergency medicine research in the Philippines: A scoping review

“…Each of these case reports, although managed in the ED or the ICU, was produced by physicians outside the field of emergency medicine. Primary authors were subspecialty physicians, most commonly from internal medicine 26,27,30,31 . Expertise of the subspecialties endocrinology, 25 cardiology, 26 neurosciences, 29,31 psychiatry, 28,30 and infectious diseases, 27 were featured; one case report was coauthored by a thoracic and cardiovascular surgeon 26 .…”

“…For case reports, rare adult medicine cases 25 , 26 , 27 , 28 and the proper management of patients with possible drug‐ or disease‐disease interactions 29 , 30 , 31 were the main topics. Each of these case reports, although managed in the ED or the ICU, was produced by physicians outside the field of emergency medicine.…”

“…Primary authors were subspecialty physicians, most commonly from internal medicine. 26 , 27 , 30 , 31 Expertise of the subspecialties endocrinology, 25 cardiology, 26 neurosciences, 29 , 31 psychiatry, 28 , 30 and infectious diseases, 27 were featured; one case report was coauthored by a thoracic and cardiovascular surgeon. 26 The lack of published case reports by emergency physicians is an important observation.…”