Laryngospasm after succinylcholine?

[Tiger26]

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Hi all--just wondering if anyone else has experienced this:


So I attempted to intubate a patient today with the standard etomidate and succ, and as I put the glidescope in, the cords are open just enough for ventilation but not enough to pass an ET tube.

We had a well functioning peripheral and the induction went smoothly. I went with 1.5 mg/kg on the succ initially and redosed with another 1 mg/kg without any effect.

Only after giving rocuronium did the cords open enough for successful tube passage.

Between a few months of anesthesia in med school and more in residency, along with ED intubations, I've done a few hundred and have never seen this before.

Thoughts? Similar experiences?

 

[RustedFox]

Bizarre.

Never had laryngospasm AFTER succinylcholine... but I do remember the distinct attitude change that I had somewhere in intern year. My thoughts were "why even use paralytics?... why not just sedate them to high heaven and tube away?" ... then after a difficult intubation with laryngospasm, I saw the benefit of paralytics.

Needless to say, I always paralyze them now.

 

[ALFI]

was a fibre optic intubation an option?? i've seen an attending do this when etomidate and succ don't open the airway quite enough to allow both the laryngoscope and ET tube in..

 

[Tiger26]

Of course, the other possibility was that the succ was defective. All of it was from the same syringe and we had no fasiculations.

However, the cords never opened and closed like I would expect with no paralytic on board, if that were the case.

 

[Hamhock]

Roc Rocks.

Why sux in a modern ED? Dose Roc at 2+mg/kg and you will have no problem.

We don't intubate like the gas folks upstairs; and we shouldn't push NMBs like the gas folks upstairs.

HH

 

[future_dr_house]

Did you have enough space to pass a bougie? I've only had one person do that on me so far but it was a full laryngospasm with the cords completely shut, so I just pulled out and gave continuous positive ventilation with the BVM to break open the spasm and more succ. It went away and I passed a bougie the next time I manipulated the mouth. Then of course just tubed over it.

 

[Tiger26]

Roc Rocks.

Why sux in a modern ED? Dose Sux at 2+mg/kg and you will have no problem.

We don't intubate like the gas folks upstairs; and we shouldn't push NMBs like the gas folks upstairs.

HH

Totally agree--however, I was in the SICU intubating with one of the surgeons, so Rocc isn't quite as high on the list up there yet

 

[MSmentor018]

Hi all--just wondering if anyone else has experienced this:


So I attempted to intubate a patient today with the standard etomidate and succ, and as I put the glidescope in, the cords are open just enough for ventilation but not enough to pass an ET tube.

We had a well functioning peripheral and the induction went smoothly. I went with 1.5 mg/kg on the succ initially and redosed with another 1 mg/kg without any effect.

Only after giving rocuronium did the cords open enough for successful tube passage.

Between a few months of anesthesia in med school and more in residency, along with ED intubations, I've done a few hundred and have never seen this before.

Thoughts? Similar experiences?

how long did you wait for the succ to take?

I had a similar exp with roc. i asked some anesthesia peeps a few days later and they've seen it with CHF patients and/or not giving "extra" time for the paralytic to kick in

 

[PMPMD]

how long did you wait for the succ to take?

Of course, the other possibility was that the succ was defective.

My money is on one of these 2 scenarios. If you had adequate anesthesia (based on loss of consciousness, absence of reflexes) you shouldn't get true laryngospasm. The latter is something we (anesthesiologists) see with inadequate anesthesia (usually at emergence).

We've had bad batches of sux in the ORs in the past couple years.

Roc is great, but with a true RSI dose (1.2 mg/kg), you'd better be darn sure you can get the tube in. 90 minutes of blockade is a LONG time to be wrong.

 

[Tiger26]

My money is on one of these 2 scenarios. If you had adequate anesthesia (based on loss of consciousness, absence of reflexes) you shouldn't get true laryngospasm. The latter is something we (anesthesiologists) see with inadequate anesthesia (usually at emergence).

We've had bad batches of sux in the ORs in the past couple years.

Roc is great, but with a true RSI dose (1.2 mg/kg), you'd better be darn sure you can get the tube in. 90 minutes of blockade is a LONG time to be wrong.

Initially waited about 45 sec as I was waiting for fasiculations to appear before making my first attempt, but had no true relaxation of cords over the ensuing 6-8 min despite succ redosing.

Otherwise, never had any myoclonus from the etomidate either, leading me to believe there was a chance the succ at least acted peripherally

 

[UnderwaterDoc]

Roc is great, but with a true RSI dose (1.2 mg/kg), you'd better be darn sure you can get the tube in. 90 minutes of blockade is a LONG time to be wrong.

I have never seen roc used in the ED for RSI, and this is the number one reason why. You fail to get that tube in and everybody will get compartment syndrome of the ass.

 

[Tiger26]

I have never seen roc used in the ED for RSI, and this is the number one reason why. You fail to get that tube in and everybody will get compartment syndrome of the ass.

Personally I use it in the ED all the time--since we don't intubate for elective reasons, a patient is going to get a tube eventually regardless of how it's put in. It's not like we can just wake them up and have their primary physiologic process reversed.

There's no contraindications and if you need to move along the rescue airway algorithm you still have an appropriately paralyzed patient

 

[The White Coat Investor]

Sure the tube wasn't too big?

 

[southerndoc]

I almost always use roc now. If you can't get a tube and can't ventilate, then cric the patient. It doesn't matter if you use succs if you can't ventilate. Most of the patients will be too hypoxic when breathing on their own.

As long as you're comfortable with your backup airway techniques, then you'll be comfortable with rocuronium.

 

[UnderwaterDoc]

Hmmm I will bring this up with our attendings for the sake of my knowledge, roc seems to be popular in the SDN crowd but like I said, I have yet to see it used in our ED. Maybe I'll start a new trend.

 

[B-Bone]

Personally I use it in the ED all the time--since we don't intubate for elective reasons, a patient is going to get a tube eventually regardless of how it's put in. It's not like we can just wake them up and have their primary physiologic process reversed.

There's no contraindications and if you need to move along the rescue airway algorithm you still have an appropriately paralyzed patient

WARNING: ANESTHESIOLOGIST BUTTING HIS STUPID NOSE IN

I realize that the ED is a different environment than the OR and you guys have a different kind of approach to airways thn we do, but I've totally seen this attitude kill someone (and yes it was in the ED when we got called to attempt to salvage a really bad situation).

My two cents is that roc is a fine drug for RSI's. I use it all the time. However, if I have any inkling that the airway might be difficult, it's sux all the way. If there's a contraindication to sux or I am really concerned about ability to intubate (or any concern about ability to ventilate), it's awake fiberoptic time. If it's a bad airway and the patient won't cooperate or whatever, I feel the lesser of two evils would be to induce the pt, keep them spontaneously breathing, and do asleep fiberoptic/video laryngoscopy/whatever your toy of choice is (with a little cricoid pressure as a probably worthless nod to the aspiration gods).

And the idea of emergent cric as a plan B is a bit out there for me. It's more like a plan E. It's down there, I'm ready to go if I need to, but I REALLY REALLY don't want to do it. It's not a trivial thing to do a surgical procedure you've rarely/never done before with shaky hands on a fat bearded dude with no neck who's skin is the same blue as your scrubs and SaO2 dropping some phat bass tones. And that is the patient who's gonna need it. When I walked into the situation I referenced above, the ED docs had already attempted cric/trach. The patient was basically dead at that point, most likely from hypoxemia, but the bilateral jugular lacerations from the cric attempts probably didn't help. I've seen seasoned ENT docs fumble emergent cric/trach in fat pts or people with abnormal anatomy (XRT, neck dissection, even just previous CEA). Not a slam dunk, by any means.

Anyway, that's just my "outside looking in" perspective. Now back to my little lurker cave.

 

[Tiger26]

Thanks for the input, B-Bone. I agree that a cric would be my plan E as well and I have no problem keeping somebody breathing with some ketamine. Still if we're intubating in the ED, then the patient is in a situation where an ET tube is the only thing conducive to life. There's just nothing elective about it and the tube has to go in somehow, even if it means walking down every step of the difficult airway algorithm.

 

[deleted109597]

I have never seen roc used in the ED for RSI, and this is the number one reason why. You fail to get that tube in and everybody will get compartment syndrome of the ass.

I get more annoyed with the improperly paralyzed patients starting to move if airway 1 doesn't work.

To the gas guys, my only response is, if you're going to screw up with roc, you're going to screw up with sux. Awake is an important ability in a proper patient.

 

[Hamhock]

Agree with the ninja and the tiger.

The decision is not roc vs. sux. (when there is a potential difficult airway).

It's NMB or no NMB.

HH

 

[pcarlson05]

For me, the length of action does not factor into my choice of paralytic, although it does to almost every one of my attendings. My thought is that the choice of paralytic never determines whether my intubation will be successful. And in cases where I can't intubate, my solution isn't to just bag the patient until the paralytic wears off, it's how can I get the tube in some other way? In the worst cases, I'd call anesthesia when in a pickle, not cric unless absolutely necessary. This is true whether the paralytic wears of in ten minutes or 90 minutes.

For this reason, I prefer roc over succ. Because if I can't intubate with succ, I'm not just going to bag the patient for ten minutes until the effect wears off--I'm going to get that tube in before then, if not with a bougie etc., then with the help my anesthesia colleagues. It's the same story with roc. Might as well go with roc then.

As for the cric, I avoid that as long as I still have options. I've heard some of my colleagues talk about how calling anesthesia "looks bad" or otherwise argue for early cric. As long as there is time, anesthesia consult should always come before cric in my mind. I don't care if it looks bad, it's the best thing for the patient, and what I would want if it's my brother or spouse on the stretcher.

Things are different at every hospital so I'm sure some will criticize my rationale, but it is what it is.

 

[B-Bone]

there is nothing wrong with bagging a pt for 10 minutes to wait for sux to wear off and potentially make things easier with a spontaneously breathing patient. there is something wrong with repeated unsuccessful intubation attempts that lead to bleeding/swelling/tissue distortion and turn a maskable pt into an unmaskable pt who is paralyzed. that's when you get into trouble. I'm not naive enough to believe that I can intubate every patient, even with all the toys at my disposal. Sometimes, just moving air (by mask, LMA, etc) is the right thing to do until you can get the help you need to get a surgical airway in a controlled manner.

 

[WilcoWorld]

Here's another attending that uses Roc as a 1st line paralytic. I've made my argument before & plenty of posters are already doing it above, so I'm not going to join in other than to say that cric isn't my plan B. Between a 1st attempt & a cric I have bougie, glidescope/CMAC, LMA (+/- Supreme) and fiberoptic. So it's really more of a plan F.

 

[pcarlson05]

there is nothing wrong with bagging a pt for 10 minutes to wait for sux to wear off and potentially make things easier with a spontaneously breathing patient. there is something wrong with repeated unsuccessful intubation attempts that lead to bleeding/swelling/tissue distortion and turn a maskable pt into an unmaskable pt who is paralyzed. that's when you get into trouble. I'm not naive enough to believe that I can intubate every patient, even with all the toys at my disposal. Sometimes, just moving air (by mask, LMA, etc) is the right thing to do until you can get the help you need to get a surgical airway in a controlled manner.

I don't disagree at all. But while bagging through the paralytic, I'd be calling anesthesia. My hope is that they would help secure the airway promptly, ideally before the paralytic even wears off. Therefore length of paralytic action shouldn't change my choice of roc vs succ.