Make Malignant Hyperthermia Training Memorable


Participating in an MH escape room is a fun and effective way to learn emergency response protocols.

There are several ways to ensure your staff is properly trained to handle a malignant hyperthermia emergency. Making them sit through yet another annual in-service or having them read dry educational materials would certainly get the job done, but creating an MH escape room would make the training memorable, challenging — and a lot of fun.

Escape rooms have been a popular form of entertainment for years. They involve teams working together to solve puzzles or clues in order to "escape" the room. It's a perfect team-building exercise, and that's why I decided to use the concept to capture my staff's attention when it was time to review how they should manage an MH emergency. Here's what it takes to pull it off.

  • Order the materials. You'll need some combination locks, lockable boxes and a lockout hasp, which can hold up to six padlocks. These boxes are ideal and can be bought on Amazon: These locks are also available on Amazon and work great, because they allow you to set unique five- character (letter, number or symbol) combinations: The lockout hasp is another Amazon purchase:
  • Come up with questions. You want to challenge and test your staff's knowledge of MH, so don't make the questions too easy. The website of the Malignant Hyperthermia Association of the United States is a good place to find useful material (see "Would You Get Out of an MH Escape Room?"). Make the questions multiple choice. Each question should have at least three possible answers (unless it is a true or false question) with each answer having a corresponding letter, number or symbol.
  • Set the rules. Spilt your staff into three-member teams, and use the same type of combination lock to secure a box for each team. The teams receive the same series of multiple choice questions, work together to come up with the answers and apply the corresponding characters to the lock in a predetermined order (top to bottom, or left to right). Teams that answer each question correctly come up with the sequence needed to unlock the box and "escape" the room. If the lock doesn't open, one or more answers are incorrect, and the team must backtrack to figure out where they went wrong. You can color-code a series of questions based on lock type and use lockout hasps to force teams to solve several locks before opening the box. Participants should be given one hour to decode the combination locks, but you'll find most teams successfully escape in much less time.
  • Reward the winners. Place some sort of prize inside the box, whether it be candy or a gift card. You can also reward the team that completes the exercise in the shortest amount of time.

LOCKED OUT Hasps that hold up to six padlocks increase the difficulty level of the exercise.

Staff members have to work as a team to solve the clues and communication is key, which are skills they'll need to manage a real-life MH crisis. I've received tons of positive feedback from participants about the creative learning method, which I plan on using to test the skills and knowledge of my staff for a variety of topics. OSM

Would You Get Out of an MH Escape Room?
KNOWLEDGE IS KEY Combination locks with letters, numbers and symbols are ideal for the MH escape room experience.

Creating an MH escape room is an alternative teaching style that will capture the attention of your staff. There are any number of questions about MH you can use to create an escape room scenario, but here are five to get you started based on information found on the website of the Malignant Hyperthermia Association of the United States (

— Danielle Bouchat-Friedman


1. What are the last four digits of the MHAUS hotline?
a. 3797 c. 9797
b. 9737 d. 3737

Answer: b
The complete hotline number is 800-644-9737. MHAUS experts are board certified anesthesiologists with special expertise in MH and proper ways to manage a crisis. They man the line 24 hours a day to provide surgical teams with real-time advice on how to stabilize stricken patients. Post the hotline number on your MH cart and make sure it's easily visible for quick reference during an emergency. Be sure phones in ORs have access to an outside line, so a staff member can reach an MHAUS expert and direct the surgical team through response efforts.

2. What are the early signs and symptoms of malignant hyperthermia?
a. decreasing ETCO₂; bradycardia; muscle rigidity; tachypnea; hypoxia
b. rising ETCO₂; bradycardia; muscle rigidity; tachypnea; hypoxemia
c. rising ETCO₂; tachycardia; muscle rigidity; tachypnea; hypoxemia

Answer: c
An increase in a patient's ETCO₂, a decrease in arterial oxygen and tachycardia are often the first signs of MH. Other symptoms to be aware of are muscle rigidity, hyperkalemia and temperature elevation. A rise in temperature is often the last sign of MH, when treatment of MH has already started. As soon as early symptoms are noticed, stop administration of volatile anesthetics. Insert activated charcoal filters into the inspiratory and expiratory limbs of the breathing circuit and hyperventilate the patient with 100% oxygen at flows of 10L/min to flush volatile anesthetics. Bring the MH cart to the OR and start reconstituting dantrolene to prepare syringes that will be administered through the patient's peripheral IV line.

3. What is the initial loading dose of dantrolene needed to stabilize patients?
a. 2.5 mg/kg b. 5 mg/kg c. 10 mg/kg

Answer: a
Dantrolene, which directly interferes with muscle contraction to decrease calcium build-up in muscle cells, is the only specific treatment for MH. Administer 2.5 mg/kg of dantrolene rapidly through an IV based on the patient's total body weight, with as much as 10 mg/kg needed for treatment of heavier patients weighing approximately 100 kg to 150 kg. Repeat until the patient responds with a decrease in ETCO2, decreased muscle rigidity and/or lowered heart rate. Large doses (>10 mg/kg) may be required for patients with persistent contractures or rigidity.

4. How much sterile water is needed to reconstitute each available version of dantrolene: Revonto from US World Meds, Dantrium from Par Pharmaceuticals and Ryanodex from Eagle Pharmaceuticals?
a. 50 ml, 10 ml and 50 ml
b. 60 ml, 60 ml and 5 ml
c. 60 ml of sterile water for all three

Answer: b
Revonto and Dantrium are packaged in 20 mg vials, which are reconstituted for injection by adding 60 ml of sterile water and shaking until the solutions are clear. Ryanodex comes in 250-mg vials, which are reconstituted with 5 ml of sterile water and shaken to ensure the solution is an orange-colored, opaque suspension. Thirty-six vials of Revonto and Dantrium and three vials of Ryanodex should be stocked to administer the initial dose.

5. How quickly should dantrolene be administered?
a. within 15 minutes
b. within 10 minutes
c. within 4 minutes

Answer: b
Dantrolene should be available for administration within 10 minutes of the decision to treat for MH, and be available for all anesthetizing locations where MH trigger agents are used. This is a slight modification of the recommendation that the drug must be administered within five minutes, which was not made based on consensus discussion. Having staff use vials of expired dantrolene to practice reconstituting the drug is an effective way to ensure they're ready to respond as quickly as possible during a real-life event. Additionally, task cards are a simple and effective way to delegate responsibilities during an emergency response and ensure responding staff members know who's assigned to begin reconstituting the dantrolene.

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