Thought I would post this case from ICU today for discussion. 42 y/o man with chronic cervical quadriplegia originally admitted for worsening sacral decub. Transferred to Icu 3 days ago for respiratory failure due to mucous plugging. Intubated on transfer without difficulty by someone else- got 200mg sux and 20 mg etomidate (he weighs about 100 kg). Had a bronch two days ago and suctioned out. Today cxr clear and looking fine on weaning trial. Extubated this AM and originally did great. Called to see him urgently about 6 hours post extubation. Sudden desaturation. When I got there sat 60's on Bipap. No breath sounds on right. Awake, pretty SOB. Got reintubation stuff together. Decided to use sux again since I thought quickest intubation would be best in this scenario. Prop 100mg, Sux 150mg. Easy reintubation. While we were securing ETT developed WCT with Rate 160. Didn't lose pulse. Gave calcium, mg, bicarb -> cardiovert X 1 to NSR and stable since. I did consider he had some risk factors for hyperK with sux but I guess I was swayed by his tolerance of the prior dose and because he had a chronic cord injury. His serum K 2 hours before this was 3.9 Anyway - seen it happen to others but first time its happened to me after almost 10 yr in the ICU. I guess I am lucky it was not a more refractory hyperK scenario.