Succinylcholine in emergent floor intubations

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divinemsm

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....so I had a scare the other night on call-called to floor for emergent intubation on a COPDer, known hx of one vessel disease, not a candidate for CABG, most recent electrolytes fine.
-On occasion, my modus operandi in sick pts on the floor is to evaluate if they are so fatigued /catecholemine depleted that I can place the tube without meds-not this guy. I induce him with etomidate and sux, place tube without difficulty-vital signs stable -write my note and head back to the call room.
-10 min later I hear " Code Blue " for the same location I just returned from-I go back to investigate and sure enough it is my guy-luckily he was resuscitated successfully.
-I know that sux acts on cardiac post ganglionic muscarinic receptors and can lead to bradying and arrest. Now I am freaked out about using it on the floor lest the sickies follow suit ....anyone have any guidelines/thought processes that they use when making the decision to paralyze or not with Sch when there are no obvious contraindications i.e >24 hrs post burn, increased IOP, etc ? I know it might seem silly, but it really frightened me in terms of my decision making :(
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divinemsm said:
....so I had a scare the other night on call-called to floor for emergent intubation on a COPDer, known hx of one vessel disease, not a candidate for CABG, most recent electrolytes fine.
-On occasion, my modus operandi in sick pts on the floor is to evaluate if they are so fatigued /catecholemine depleted that I can place the tube without meds-not this guy. I induce him with etomidate and sux, place tube without difficulty-vital signs stable -write my note and head back to the call room.
-10 min later I hear " Code Blue " for the same location I just returned from-I go back to investigate and sure enough it is my guy-luckily he was resuscitated successfully.
-I know that sux acts on cardiac post ganglionic muscarinic receptors and can lead to bradying and arrest. Now I am freaked out about using it on the floor lest the sickies follow suit ....anyone have any guidelines/thought processes that they use when making the decision to paralyze or not with Sch when there are no obvious contraindications i.e >24 hrs post burn, increased IOP, etc ? I know it might seem silly, but it really frightened me in terms of my decision making :(
Click to expand...

This is VERY interesting. EXACT same thing happened to me with the exception that we used propofol (but much less....we used perhaps 90 mg on a patient that weighed 350lbs). For mx relax I used sux. Next thing I know the guy arrests. We then have to do CPR, epi, atrop. We succesfully resuscitate him.

My differential:
-Vagal from intubation
-The propofol and/or etom both are theoretically cardiac depressants although I used a terribly 'low' dose and you used etom (which still may decrease the HR)
-I agree with you. In kids, Sux is notorious for cause brady. I've seen this happen once before as well. Since we are using two drugs..both sux and prop/etom...hard to say which is the causative agent...or if it's the vagal from the intub. I'm willing to say it's from SUX.

it's SCARY!!
 
it's not the sux. muscarinic mediated cardiac arrest from sux occurs within seconds of administration. it wasn't you. this guy had multiple other reasons to crump.
 
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many times a post intubation "PEA arrest" in a pt with severe COPD is due to overzealous bagging -> hyperinflation -> decreased CO
 
Why use sux? Most guys I tube on the floor with just some etomidate. I only push the sux once I feel I need to. Most of the these guys can be tubed with 10-20mg of etomidate
 
I always stayed away from sux for the fact that most of our emergent intubations were in the ICU. Most of the patients had been in the unit for awhile and I feared cardiac arrest with these immobile critical patients secondary to hyperkalemia. I would either try just etomidate and intubate with the patient still spontanous ventilating (can be tough) or usually just do etomidate and nimbex (had alot of renal patients) and ventilate them for the 2 minutes and then intubate.
Tried propofol once in the ICU as I thought that I had some cushion with the BP and found out that I didn't, she went really low for about 10 minutes (sucked).
 
ssmallz said:
Why use sux? Most guys I tube on the floor with just some etomidate. I only push the sux once I feel I need to. Most of the these guys can be tubed with 10-20mg of etomidate
Click to expand...

I go with 50 - 100 mg propofol and only use sux when necessary.
 
Jeff05 said:
it's not the sux. muscarinic mediated cardiac arrest from sux occurs within seconds of administration. it wasn't you. this guy had multiple other reasons to crump.
Click to expand...
+1. in my humble opinion, sux will give you your best look. unless there's a contraindication, for an emergent intubation sux benefit > risk
 
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sux's muscarinic effect is only after a second dose of the drug, the first dose sensitizes the receptors, the second dose is the kick in the balls. Given that info, I'd assume that only 1 dose was given, and it was unlikely that you caused anything given this patient's history.
 
Etomidate sucks. Succinylcholine sucks. Propofol sucks. All the drugs we routinely use suck in these situations... except Brutane.

-copro
 
I'm with Copro on this one.

During my residency, I estimate about 70% of my ICU intubations were with lidocaine and a few kind words. This excludes strictly code intubations which were with nothing but my considerable charm. Now I'm in fellowship at a different institution and when I talk about awake, topicalized DLs, they look at me like i'm from Mars. They're all about etomidate and succ here, ignoring all the circumstantial data about etomidate and worse outcomes.

I really like to avoid giving anything that can come back to haunt me. No matter how little I give, and no matter how ardently I can argue that my 20 of propofol isn't the cause of hypotension 30 minutes later, the finger of blame can still be cast by the ignorant. That and the incessant focus on "anesthesia" as the cause of all ICU hypotension distracts from the real consideration of other problems that are contributing to the patient's poor status (the aforementioned overzealous ventilation, for example).
 
When you talk about topicalization of an urgent intubation, what exactly are you guys doing? Nasal's? Oral's? Dl's? Glidescope? FOB? 2% or 4% given via what device...atomizer? updraft? I'm looking for a quick topical technique with minimal setup...of course, I dontming using brutane myself.
 
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coprolalia said:
Etomidate sucks. Succinylcholine sucks. Propofol sucks. All the drugs we routinely use suck in these situations... except Brutane.

-copro
Click to expand...

Wow - I think this might represent a significant intercontinental difference!

I can guarantee that if I intubated someone via direct laryngoscopy (or video laryngoscopy or iLMA or pretty much any method other than awake FOI or at a cardiac arrest) without some sort of sedative agent I would be crucified.:scared:
If I choose not to use a relaxant I would be seriously questioned. I might be able to get away with no relaxant and a slug of alfentanil or (better still) remifentanil - but I would need a good reason not to have optimised my chances of intubation on the first attempt.
 
pushthesux said:
When you talk about topicalization of an urgent intubation, what exactly are you guys doing? Nasal's? Oral's? Dl's? Glidescope? FOB? 2% or 4% given via what device...atomizer? updraft? I'm looking for a quick topical technique with minimal setup...of course, I dontming using brutane myself.
Click to expand...

I like 5% ointment on a tongue blade, slowly working from the tip of the tongue to the base, taking short breaks in btwn applications. Work the blade as far back as you can and if you get it right, you can practically tickle their epiglottis without eliciting a gag. Then I use 4% lidocaine solution in a sprayer to get the hard/soft palate, uvula, and then downward toward the larynx. They'll usually cough, which may spread the lido around. Then I'll grease the ETT and Mac blade with the ointment (the mac blade is better for this application because you can keep the blade midline, right where you've topicalized and avoid hitting a lot of ancillary, un-numbed structures, off to the side). I cover their eyes and tell them, "here comes that tongue depressor again, but with more pressure this time."
 
cchoukal said:
I'm with Copro on this one.

During my residency, I estimate about 70% of my ICU intubations were with lidocaine and a few kind words. This excludes strictly code intubations which were with nothing but my considerable charm. Now I'm in fellowship at a different institution and when I talk about awake, topicalized DLs, they look at me like i'm from Mars. They're all about etomidate and succ here, ignoring all the circumstantial data about etomidate and worse outcomes.

I really like to avoid giving anything that can come back to haunt me. No matter how little I give, and no matter how ardently I can argue that my 20 of propofol isn't the cause of hypotension 30 minutes later, the finger of blame can still be cast by the ignorant. That and the incessant focus on "anesthesia" as the cause of all ICU hypotension distracts from the real consideration of other problems that are contributing to the patient's poor status (the aforementioned overzealous ventilation, for example).
Click to expand...

No question...I pretty much always try to give just 1 of versed or if they're pretty much out of it, do just a DL and stick the tube in. However, this pt was fairly obese and was uncooperative with allowing me to put a blade in her mouth. If she's a 50kg old lady, BRUTANE may work. But when they are 7 times that strength and the oral aperture is not that big....you gotta push more than propofol/etom.

my 2 cents.
 
SleepIsGood said:
No question...I pretty much always try to give just 1 of versed or if they're pretty much out of it, do just a DL and stick the tube in. However, this pt was fairly obese and was uncooperative with allowing me to put a blade in her mouth. If she's a 50kg old lady, BRUTANE may work. But when they are 7 times that strength and the oral aperture is not that big....you gotta push more than propofol/etom.

my 2 cents.
Click to expand...

As with everything else, it depends on the situation. I used to separate them into 2 categories, either I have time to dick around or I dont. If I dont then usually that means they are so out of it that brutane is fine (+/- additional meds like propofol/esmolol/etc if BP high and worried about something like an aneurysm. If you have time, then reassess if they look like a potentially difficult airway, risk of losing airway vs hypotension vs aspiration, etc... just like in the OR. If you have time and your goal is to maintain spontaneous respiration topicalize with an awake look, or titrate midazolam or ketamine or your drug of choice. I used to titrate midazolam until they were still spontaneously ventilating but did not respond to a vigorous jaw thrust. Usually if they didnt resond to this they didnt respond to a DL. If they were still kicking after 5 of midazolam I slipped in some propofol in 10-20mg increments. Now if you know they are going to be an easy airway or aspiration is your main concern then a rapid sequence is still probably your best bet with induction agent of choice and succ. Having said that my personal perference is to avoid etomidate and succ in a lot of these ICU players if possible. The main thing is that if they can be mask ventilated (and arent actively puking) then its not an emergency.
 
Out of curiosity someone on here mentioned that they would not give sux to patients in the ICU if they've been immobilized for a long time.

What if you have checked/asked and found the K to be wnl. Is the thought process the concern of the 'up regulation' of the receptors. If so, isnt that more for 'prolonged' immobility...ie in terms of months?
 
there are many painful procedures that can be done without anesthesia. intubation is a very stimulating, painful, unpleasant procedure.

i think we do a comprehensive 3 year residency in order to have some finesse. anyone can ram a mac 3 down the piehole and jam a tube in it.

it takes real clinical acumen to smoothly induce a sick patient, or at least sedate them, and swiftly and safely control the airway. i think it is absolutely inhumane to do otherwise (exceptions - completely obtunded, profoundly hypotensive, etc.). most of the time, it IS possible to make the patient not remember/feel the tube.


the main cause of aspiration during intubation is a light patient. get them as deep as possible and optimize your view the first time. this is my limited clinical experience.
 
ssmallz said:
Why use sux? Most guys I tube on the floor with just some etomidate. I only push the sux once I feel I need to. Most of the these guys can be tubed with 10-20mg of etomidate
Click to expand...

Sometimes with etomidate you get myoclonus and need relaxant to open the patient's mouth and get a decent view. Also, if a patient has a full stomach, etomidate will not prevent them from vomiting. In both cases, succinylcholine is very helpful to prevent the problem.
 
coprolalia said:
Etomidate sucks. Succinylcholine sucks. Propofol sucks. All the drugs we routinely use suck in these situations... except Brutane.

-copro
Click to expand...

One particular study found that attendings versus residents had lower complication rates for "floor" intubations. However, the only identified difference was that the attendings were much more likely to be use muscle relaxants.

I'd say that as far as meds go, it's all a matter of degree. You're usually not intubating someone from a wide awake state and then expecting an incision shortly thereafter as with normal OR cases. Therefore the amounts of induction drug become much less; and less worry about immediately crumping. As far as the OP though, 30mins is way too long for our typical meds. Often it's hyperventilation/autopeep; possibly a pneumo from blebs.
 
I have a scenario.

called by medicine team to the ED to intubate a patient due to "pt having difficulty maintaining the airway." Pt is a 75 year old man hx of a-fib treated recently with lovenox and coumadin. Pt had an embolic stroke approx two weeks ago and hx of multiple embolic strokes going back about 15 years. This evening pt came to ED from NH for mental status changes, did I mention hx of dementia as well. CT scan showed a 1.5 x 2 cm intra-parencyhmal hematoma acute vs chronic not distinguished by radiology. On arrival in the ER patient was communicating, at the time of the page mental status had deteriorated, pt is unresponsive to verbal stimuli, withdraws to painful stimuli. What medications would you use? This was the first time I had been asked to evaluate a patient for intubation, my hands were shaking as I was drawing up the drugs I chose, haha.
 
DreamMachine said:
Why exactly were your hands shaking?
Click to expand...

Sorry to put words into Merc44's mouth, but his hands were probably shaking because, as stated, it was the first time Merc44 had been asked to evaluate a patient for (emergent) intubation.
 
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