How to manage violent ballism during emergence from anesthesia?

Management of Violent Ballism During Emergence from Anesthesia

For immediate management of violent ballism during emergence from anesthesia, administer a dopamine receptor blocking agent such as haloperidol, which is highly effective in controlling ballistic movements. 1

Understanding Emergence Ballism

Emergence from anesthesia represents a critical transition from a controlled to an uncontrolled situation, with potential for serious complications including violent movements:

• Tracheal extubation and emergence are high-risk phases of anesthesia that can lead to significant morbidity and mortality 2
• Violent ballistic movements during emergence are dangerous and require immediate intervention to prevent patient injury and airway complications 2
• Ballism is characterized by abrupt onset of vigorous, rapidly executed, poorly patterned involuntary movements of the limbs 3

Immediate Management Algorithm

Step 1: Airway Protection

• Maintain the airway and administer 100% oxygen 2
• Consider delaying extubation if violent movements are present or anticipated 2
• Use a bite block to prevent occlusion of the tracheal tube if the patient bites down 2

Step 2: Pharmacological Intervention

• First-line treatment: Administer dopamine receptor blocking agents 1, 4
  • Haloperidol is well-established for controlling ballistic movements 3
  • For elderly patients, consider sulpiride due to fewer side effects 3
• Alternative options:
  • Chlorpromazine can be effective for severe cases 3
  • Tetrabenazine may be considered for persistent symptoms 4
  • Sertraline (a serotonergic agent) has shown rapid response in some cases and may offer better side effect profile than dopamine blockers 5

Step 3: Anesthetic Management

• Consider deepening anesthesia temporarily to control violent movements 2
• Use remifentanil infusion to suppress movement and cough reflex during emergence 2
• Ensure adequate analgesia as pain can trigger emergence agitation 2

Step 4: Positioning and Physical Safety

• Position the patient in head-up (reverse Trendelenburg) or semi-recumbent position to optimize respiratory mechanics 2
• Ensure adequate staffing to prevent patient self-injury during violent movements 2
• Remove potential hazards from the immediate environment 2

Prevention Strategies

• Develop an extubation strategy before starting anesthesia 2
• Risk stratification: Identify patients with potential for emergence complications 2
• Consider "deep extubation" in appropriate patients to reduce airway stimulation that may trigger ballistic movements 2
• The Bailey maneuver (exchanging the tracheal tube for an LMA before emergence) may reduce the risk of airway complications during emergence 2

Post-Emergency Care

• Monitor the patient closely for at least 24 hours following a ballistic episode 2
• Evaluate for underlying causes of ballism (though emergence-related ballism is typically transient) 4
• If ballistic movements persist beyond the immediate post-anesthetic period, consider neurological consultation 4

Common Pitfalls and Caveats

• Avoid excessive sedation which may compromise respiratory drive 2
• Be prepared for potential post-obstructive pulmonary edema if airway obstruction occurs during ballistic movements 2
• Do not assume all emergence movement disorders are benign - some may indicate serious underlying conditions requiring further investigation 4, 6
• Remember that while most emergence-related ballism resolves spontaneously, some cases may require ongoing treatment 3, 1