MH Crisis. Have you done all that can be done to be prepared?

No matter how often you work to prepare your staff, a MH crisis is going to be exceptionally hard at the moment of an event. The best thing you can do is to ensure the staff are educated, trained, and prepared. We have provided you some helpful tips at ensuring your readiness:

**MALIGNANT HYPERTHERMIA (MH)

EMERGENCY RESPONSE & COMPLIANCE MANUAL** (ASC/OBL/Procedure Centers)

TABLE OF CONTENTS

1. Policy & Purpose

2. Scope

3. Definitions

4. MH Triggering Agents

5. Early Recognition Criteria

6. Emergency Response Protocol (Step-by-Step)

7. Dantrolene Preparation & Dosing Guide

8. MH Cart Requirements & Inventory Log

9. Staff Roles During MH Event

10. Transfer & Escalation Procedures

11. Post-Event Management

12. Staff Training & Drill Requirements

13. Documentation Requirements

14. Quality Assurance & QAPI Integration

15. Forms & Logs (Fillable Templates)

1. POLICY & PURPOSE

The facility maintains a fully equipped malignant hyperthermia (MH) response system to ensure rapid identification and treatment of MH events in accordance with:

• CMS Conditions for Coverage (ASC)

• The Joint Commission standards

• American Society of Anesthesiologists guidelines

• Malignant Hyperthermia Association of the United States recommendations

2. SCOPE

Applies to:

• All anesthesia providers

• Registered nurses

• Surgical technologists

• Medical staff

• Emergency response personnel

3. DEFINITIONS

Malignant Hyperthermia (MH):A pharmacogenetic disorder triggered by certain anesthetic agents causing uncontrolled skeletal muscle metabolism.

4. MH TRIGGERING AGENTS

Known Triggers

• Volatile anesthetics:

  • Sevoflurane

  • Desflurane

  • Isoflurane

• Succinylcholine

Non-Triggering (Safe) Agents

• Propofol

• Ketamine

• Midazolam

• Fentanyl

• Rocuronium / Vecuronium

• Local anesthetics

5. EARLY RECOGNITION CRITERIA

MOST IMPORTANT (EARLY SIGNS):

• Rapid rise in ETCO₂

• Tachycardia

• Muscle rigidity (especially jaw)

LATE SIGNS:

• Hyperthermia

• Dark urine (myoglobinuria)

• Acidosis

• Hyperkalemia

6. EMERGENCY RESPONSE PROTOCOL

IMMEDIATE ACTIONS (0–5 MINUTES)

1. STOP triggering agents immediately

2. Call MH CODE

3. Hyperventilate with 100% O₂ at high flow

4. Discontinue volatile anesthetics

5. Activate MH cart

TREATMENT ACTIONS

6. Administer Dantrolene immediately

7. Initiate active cooling:

   • Ice packs (groin, axilla, neck)

   • Cold IV saline

8. Monitor:

   • ETCO₂

   • Core temperature

   • ABGs

   • Electrolytes

7. DANTROLENE DOSING GUIDE

Initial Dose:

• 2.5 mg/kg IV push

Repeat:

• Every 5 minutes until symptoms controlled

• Max cumulative: 10 mg/kg (or higher per MD)

RECONSTITUTION

• Dantrium/Revonto: 20 mg vial + 60 mL sterile water

• Ryanodex: 250 mg vial + 5 mL sterile water

👉 Ryanodex preferred for rapid response

8. MH CART REQUIREMENTS

MANDATORY CONTENTS

• Dantrolene (minimum supply per guidelines)

• Sterile water for injection

• Syringes (large volume)

• Cooling supplies

• Sodium bicarbonate

• Insulin + Dextrose

• Calcium chloride

• Antiarrhythmics

• Foley catheter kit

• Temperature probes

MH CART LOG (Sample)

Date

Checked By

Dantrolene Count

Expiration Verified

Supplies Complete

Notes

9. STAFF ROLES DURING MH EVENT

Anesthesia Provider

• Leads response

• Administers dantrolene

Circulating Nurse

• Activates MH cart

• Documents timeline

Scrub Tech

• Assists with supplies

Runner

• Mixes dantrolene

• Retrieves additional supplies

10. TRANSFER & ESCALATION

• Stabilize patient

• Arrange emergency transfer to higher level of care

• Notify receiving hospital of MH event

11. POST-EVENT MANAGEMENT

• ICU monitoring (24–48 hrs)

• Monitor for recurrence

• Document fully

• Report to:

  • Malignant Hyperthermia Association of the United States registry

12. STAFF TRAINING & DRILLS

REQUIREMENTS:

• Annual MH competency validation

• Mock drill at least annually (best practice: quarterly)

DRILL DOCUMENTATION LOG

Date

Scenario

Staff Involved

Response Time

Deficiencies

Action Plan

13. DOCUMENTATION REQUIREMENTS

• Event timeline

• Medications administered

• Vital signs

• Transfer details

• Incident report

14. QUALITY ASSURANCE (QAPI)

Include:

• Drill performance review

• Cart audit compliance

• Staff competency tracking

• Incident trending

15. FORMS & TEMPLATES (READY TO USE)

A. MH EVENT FLOW SHEET

• Time-based intervention tracking

• Medication log

• Vital signs grid

B. MH CRASH CART CHECKLIST

• Daily / weekly verification

• Expiration tracking

C. STAFF COMPETENCY CHECKLIST

• Recognition of MH

• Dantrolene preparation

• Emergency response steps

D. POST-EVENT REVIEW FORM

• Root cause analysis

• Performance scoring

• Corrective actions