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Succinylcholine in Trauma

bensonblues at comcast.net bensonblues at comcast.net
Fri Aug 22 05:40:30 BST 2008


Anthony and Garth,

Succinylcholine (SCh) has its problems when used in the trauma victim. American anesthesia people will tell you that Rapid Sequence Induction (RSI) was invented especially for the trauma victim who is assumed to be non-fasting. RSI is the procedure of choice for the trauma victim and consists of 1) hyperoxygenation, 2) anesthesia or sedation with whatever, 3) then pretreatment with a small dose of a non-depolarizing neuromuscular blocker (NMB) such as vecuronium or pancuronium, wait a minute, then 4) administer a fully-paralyzing dose of SCh, followed by immediate tracheal intubation without ventilating the patient (no need to introduce air into the gastric bowl full of macaroni and beer). This procedure takes a little time to complete.

The reason for pretreatment with a non-depolarizing agent is that SCh is a depolarizing NMB which if given as a bolus in usual paralysis-inducing amounts results in the initial contraction of almost all of the muscles in the body (those innervated using acetylcholine as the neurotransmitter). This results in several potential problems, the most important being increase in intragastric pressure secondary to contraction of the abdominal muscles. This, combined with failure of the cardiac sphincter can result in the transportation of macaroni and beer into the airway, increasing the difficulty of the airway management and potentially increasing the morbidity and mortality of the patient (I've seen this at least a dozen times in my career). In addition, SCh may cause protrusion of intraocular contents if there is occult injury to the globe of the eye, can in theory increase intracranial pressure if head injury, fatal hyperkalemia (I seen this a couple times) if used on a patient in DKA
, renal failure, crush injury, or burns.

There are many ways to skin a cat, and you should use diffent ways depending on the characteristics of the cat. In the field, although it is not used much in Detroit for some reason (probably political), I believe I would use nasotracheal intubation more often than not in the breathing patient (except in head injury), combined with a little sedation (you name it: ketamine (I prefer), morphine (watch the BP), fentanyl (OK by me), midazolam (watch the BP), ad nauseum. If I had to use the laryngoscope, I'd use ketamine and finesse (it usually is all that is needed, depending upon your experience). If I had to use SCh (and sometimes you do), I'd first give 1/10 of the full-paralyzing dose, then a minute later push the rest. Doing it this way somewhat decreases the intensity of the defacsiculations/muscular contractions.

I intubate at least one person a day in the ED who is non-fasting, tends to have multiple medical problems, and is usually in extremis. I use ketamine (propofol if head injury) and vecuronium .25 mgkg. The usual dose of vecuronium is 0.1 mg/kg, but higher doses have been shown to have a faster onset that approaches the onset of SCh. In the unlikely event that you need to reverse the drug, 1 - 2 mg of physostigmine should do it. I stick with this method because it has worked for me and my patients (so far, knock on wood) for more than 20 years.

Really, whatever way you choose to skin your cat should be the one that experience has proven to you to be the safest and most effective. Your track record will speak for itself in the end.

Don Benson, DO, FACEP
St. John Hospital
Detroit


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