List Archives

Fri Aug 22 11:51:22 BST 2008

There is likely to be little benefit from cricoid pressure (Sellick's
manoeuvre) in patients who already have an NG tube in situ. Classical RSI
involves administration of a sleep dose of induction agent - usually
thiopentone - followed immediately by 1.5-2mg/kg of suxamethonium. The dose
of Thiopentone can be reduced according to the haemodynamic state of the
patient. It is widely believed that the decrease in ICP secondary to thio
offsets the increase secondary to suxamethonium leading to minimal net
change in pressure. The patient is intubated without ventilation roughly one
minute following the sux - essentially when fasciculations finish.
Various modifications of this exist - the "modified RSI". These
modifications either alter the speed of induction or the drugs or both. 
All have their proponents and disadvantages...mostly anecdotal/theoretical
with minimal evidence to support their pros or cons.

Dom

Dr Dominik Krzanicki
MBChB (Hons), MRCS (Eng), Dip IMC (RCS Ed)
StR Anaesthetics and Intensive Care

E-mail: dominikkrzanicki at hotmail.com
Phone: +44 (0) 7801 118790

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of gamal ejaimi
Sent: 22 August 2008 09:20
To: Trauma &amp; Critical Care mailing list
Subject: RE: Succinylcholine in Trauma

Hi..
The aim of RSI is to guard against aspiration in pts who are regarded as has
a full stomach or with bleeding in oropharynx. So if you precurization was
done to prevent fasciculation this will take time while Sellick"s maneuver
and not to ventilate the pt manually is essential. Thus all procedure from
administration of Succinylcholine (SCh) should not be more than 1 minute. By
the way aspiration of the stomach via NG tube is advisable. Three persons
must be available for procedure. Do not forget  Manual In-Line Intubation
because cervical injury can not be excluded at that time.
With thanks.
Please let us updated > From: bensonblues at comcast.net> To:
trauma-list at trauma.org> Subject: Succinylcholine in Trauma> Date: Fri, 22
Aug 2008 04:40:30 +0000> > 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.> > The
 re 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> --> trauma-list : TRAUMA.ORG>
To change your settings or unsubscribe visit:>
http://www.trauma.org/index.php?/community/
_________________________________________________________________
Tired of having no room left in your inbox? Windows Live Hotmail now gives
you 5GB of FREE storage! Get your free Windows Live Hotmail account here!
http://get.live.com/mail/overview
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

Internal Virus Database is out of date.
Checked by AVG - http://www.avg.com 
Version: 8.0.138 / Virus Database: 270.6.5/1618 - Release Date: 18/08/2008
06:51

List Archives

For your convenience, find the Trauma List Archive Below

Succinylcholine in Trauma