Batra, Sonal

Norberg, Bailey

Pierce, Ayal Z

English

George Washington University: Health Sciences Research Commons (HSRC)

Himmelfarb Health Sciences Library, The George Washington University Health Sciences Research Commons Emergency Medicine Faculty Publications Emergency Medicine 12-1-2021 Accidental Ocular Rocuronium Exposure. Ayal Z Pierce Sonal Batra Bailey Norberg Follow this and additional works at: https://hsrc.himmelfarb.gwu.edu/smhs_emerg_facpubs  Part of the Emergency Medicine Commons, and the Trauma Commons hour.3 Therefore, the occlusion myocardial infarctiongroup might have been more likely to undergo morefrequent serial ECGs than the no-occlusion myocardialinfarction group, introducing the risk of a detection bias.Serial ECGs might improve the sensitivity of ECG forocclusion myocardial infarction, so more frequent ECGsin the occlusion myocardial infarction group could havehelped identify more occlusion myocardial infarctions inthat group.4,5 On the other hand, less frequent serialECGs in the less symptomatic no-occlusion myocardialinfarction group might have failed to detect dynamic STdeviation and, therefore, lowered the likelihood ofmodified Sgarbossa criteria or the original SgarbossaCriteria being false positive for occlusion myocardialinfarction. An imbalance in the number of serial ECGsbetween the occlusion myocardial infarction and no-occlusion myocardial infarction groups might influencethe test characteristics of both modified Sgarbossa criteriaand original Sgarbossa Criteria by deflating sensitivity andinflating specificity to some degree.The authors presume that “there is no reason to believethat any of [the study’s] limitations disproportionatelyaffected the diagnostic accuracy of either the modifiedSgarbossa criteria or the original Sgarbossa Criteria.” This isalso likely to be true of the possible imbalance in the numberof ECGs per subject between the groups. However, avalidation study with a defined serial ECG protocol in boththe groups or an adjustment for the number of ECGs persubject (as a possible covariate) would be necessary todetermine whether serial ECG differentially affects thediagnostic accuracy of modified Sgarbossa criteria andoriginal Sgarbossa Criteria for occlusion myocardialinfarction in the setting of ventricular paced rhythm.Calvin J. Tan, MDIan S. deSouza, MDDepartment of Emergency Medicine, Downstate/Kings CountyHospital, State University of New YorkBrooklyn, NYhttps://doi.org/10.1016/j.annemergmed.2021.08.018Funding and support: By Annals policy, all authors are Q4required to disclose any and all commercial, financial, andother relationships in any way related to the subject of thisarticle as per ICMJE conflict of interest guidelines (seewww.icmje.org). The authors have stated that no suchrelationships exist.1. Dodd KW, Zvosec DL, Hart MA, et al. Electrocardiographic diagnosis ofacute coronary occlusion myocardial infarction in ventricular paced rhythmusing the modified Sgarbossa criteria. Ann Emerg Med. 2021;78:517-529.2. Eriksson D, Khoshnood A, Larsson D, et al. Diagnostic accuracy ofhistory and physical examination for predicting major adverse cardiacevents within 30 days in patients with acute chest pain. J Emerg Med.2020;58:1-10.3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guidelinefor the management of patients with non-ST-elevation acute coronarysyndromes: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines. J Am Coll Cardiol.2014;64:e139-e228.4. Fesmire FM, Percy RF, Bardoner JB, et al. Usefulness of automatedserial 12-lead ECG monitoring during the initial emergency departmentevaluation of patients with chest pain. Ann Emerg Med. 1998;31:3-11.5. Tanguay A, Lebon J, Lau L, et al. Detection of STEMI using prehospitalserial 12-lead electrocardiograms. Prehosp Emerg Care.2018;22:419-426.Accidental Ocular Rocuronium ExposureTo the Editor:Rocuronium is a commonly used paralytic in rapidsequence intubation in the emergency department(ED).1,2 Despite familiarity with this critical drug, little isknown about the expected course and appropriatemanagement of accidental exposures. We report a case oflocal symptoms after accidental exposure to rocuroniumin the eye.A healthy 31-year-old woman was working in an urbanacademic ED. While drawing up 100 mg of rocuroniumbromide, the lid on one vial opened (Figure), and sheaccidentally splashed rocuronium into her left eye. Themaximum contamination of the eye would have been 50mg though the exact amount was unknown. Sheimmediately went to the nearest eyewash station andirrigated her eye for 5 minutes. Afterwards, she presented toEmployee Health, who sent her to the ED, where shearrived 30 minutes after exposure.The patient complained of “heaviness” of her lefteyelid and mild blurry vision. She denied any respiratorysymptoms, extremity weakness, headache, double vision,eye pain, or sensory deficits. On examination, she had apartial forehead crease flattening with eyebrow raise onher left side. Resistance to eye-opening was slightlyweaker on the left eye compared to the right. Thepatient had a symmetric smile; pupils were equal, round,and reactive to light. She had no lag, weakness, ornystagmus with extraocular eye movements. Theremainder of her neurologic examination wasunremarkable, as were her cardiac, pulmonary, andabdominal examinations.The National Capital Poison Control was contacted forguidance, but they had no reports of mucosal exposure ofrocuronium. The patient was observed in the ED and, after2 hours, had complete resolution of her symptoms and804 Annals of Emergency Medicine Volume 78, no. 6 : December 2021Correspondencefacial weakness. The patient never complained of anyrespiratory symptoms or other systemic abnormalities. Shewas safely discharged and able to return to work.With the growing popularity of rocuronium in rapidsequence intubation, accidental exposures should beunderstood and properly managed. While the exposure ofrocuronium to the eye has not been reported, there arecase reports of insidious and prolonged neuromuscularblockade with subcutaneous exposure after intravenousinfiltration.3-5 The most life-threatening sign ofrocuronium exposure would be respiratory depressionrequiring intervention. While our patient only exhibitedlocal signs and symptoms that self-resolved within 2hours, patients with mucosal absorption must be carefullymonitored given the potential for systemic paralysis andunknown duration of effects.Immediate decontamination should be performed,and dosage exposure compared to the patient’s weightshould be noted. Observation with pulse oximetry, end-tidal monitoring, and sequential negative inspiratoryforce testing are all relatively simple monitoringstrategies that can be used. Should a patient exhibit signsof worsening respiratory depression, such asdesaturations, decreasing end-tidal, or worseningnegative inspiratory forces, intravenous sugammadexwould be the definitive treatment before symptomsbecome life-threatening. Sugammadex is a readilyavailable reversal agent and has a rapid onset of action.Though rare, hypersensitivity, anaphylaxis, andbradycardia can occur. Therefore, with accidentalmucosal exposure of rocuronium, we recommend closemonitoring for this self-limiting course as the first lineuntil the effects of the paralysis resolve.Ayal Z. Pierce, MDSonal Batra, MD, MSTDepartment of Emergency MedicineGeorge Washington University School of Medicine and HealthSciencesWashington, DCBailey Norberg, RNDepartment of Emergency MedicineGeorge Washington University HospitalWashington, DChttps://doi.org/10.1016/j.annemergmed.2021.09.426Funding and support: By Annals policy, all authors arerequired to disclose any and all commercial, financial, andother relationships in any way related to the subject of thisarticle as per ICMJE conflict of interest guidelines(seewww.icmje.org). The authors have stated that no suchrelationships exist.1. April MD, Arana A, Pallin DJ, et al. Emergency department intubationsuccess with succinylcholine versus rocuronium: A national emergencyairway registry study. Ann Emerg Med. 2018;72:645-653.2. Tran DTT, Newton EK, Mount VAH, et al. Rocuronium vs. succinylcholinefor rapid sequence intubation: a Cochrane systematic review.Anaesthesia. 2017;72:765-777.3. Timmermann TN, Mongan PD, Hoefnagel, et al. Management ofsubcutaneous infiltration of rocuronium: A case report. J Clin Anesth.2021;71:110203.4. Doshu-Kajiura A, Suzuki J, Suzuki T. Prolonged onset and duration ofaction of rocuronium after accidental subcutaneous injection in apatient with chronic renal failure-a case report. JA Clin Rep. 2021;7:18.5. Navare SR, Garcia Medina O, Prielipp RC, et al. Sugammadex reversal ofa large subcutaneous depot of rocuronium in a dialysis patient: a casereport. A&A Pract. 2019;12:375-377.Figure. Vial of rocuronium used in RSI.Volume 78, no. 6 : December 2021 Annals of Emergency Medicine 805Correspondence

Accidental Ocular Rocuronium Exposure.

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Accidental Ocular Rocuronium Exposure.

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