M OUTH, MANDIBLE

E XCESSIVE WEIGHT
D EFORMITY
I NCISORS
C -SPINE
T HYROMENTAL DISTANCE
U VULA
B URNS
E MESIS
S TRIDOR
Conquer Difficult Airways
Succinylcholine Side Effects
Succinylcholine is a depolarizing paralytic and will cause muscles to
contract prior to causing paralysis. Non-depolarizing paralytics such as
vecuronium do not cause muscle contractions and can be given in small
doses prior to administration of succinylcholine to prevent muscle
fasciculations. Non-depolarizing agents have a longer lasting effect than
succinylcholine, and are used to paralyze patients for longer time periods
after the airway has been secured.
Fasciculation: Within 30-60 seconds following administration of
succinylcholine, muscles fasciculate (contract) uncontrollably as muscle
tissue depolarizes. Fasciculation typically lasts for less than 15 seconds.
These involuntary muscle contractions don't usually pose a problem unless
the patient has skeletal fractures that movement could aggravate. You can
administer a decreased dose of a non-depolarizing muscle relaxant, such
as Vecuronium, two minutes prior to succinylcholine administration to
prevent muscle fasciculation.
Elevation of intracranial, intragastric and intraocular pressure:
Succinylcholine transiently increases pressure within the brain, stomach
and eyes. Thus, EMS providers should anticipate vomiting and minimize
the potential for aspiration. Succinylcholine is contraindicated in patients
with penetrating eye injuries and glaucoma. Patients with increased
intracranial pressure (ICP) often require airway protection and controlled

ventilation. Therefore, the temporary undesirable flux in ICP, caused by

succinylcholine, is offset by the benefits of definitive airway management
facilitated with succinylcholine use.
Lung sounds such as stridor can be difficult to recognize if you havent
heard them before. Click here to hear a variety of lung sounds, including
stridor, rales, and wheezing.
http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

Conquer Difficult Airways

Succinylcholine Side Effects
Hyperkalemia: All patients who receive succinylcholine experience a slight
increase in their serum potassium, which isn't usually a clinical concern.
However, a small number of patients can have a much greater, lifethreatening potassium increase. These include patients with burns, crush
injuries, spinal cord injuries and extensive necrotic soft-tissue infection.
These patients tend to develop an increased number of neurotransmitter
receptors on skeletal muscle cells, resulting in an exaggerated release of
potassium.
This often takes several hours to days to develop and usually is not a
prehospital concern. However, take care when managing a patient who
was burned or crushed days previously and now presents to EMS. The
potential for excessive potassium leak in some burn patients may persist
for up to two years.
The most significant complication of hyperkalemia is cardiac arrhythmias,
including complete heart block, ventricular fibrillation and asystole. Earlier
ECG signs include tall, peaked T waves, QRS widening and flattening of
the P wave. Patients may also complain of muscle weakness, nausea,
vomiting and diarrhea.
Treatment of hyperkalemia is best conducted at the ED. On confirmation of
true hyperkalemia, the treatment plan must include stabilizing cardiac
tissue, shifting potassium back into the cells and removing potassium from
the body.

Conquer Difficult Airways

Succinylcholine Side Effects

Bradycardia: The occurrence of bradycardia in some patients who receive
succinylcholine remains unpredictable. However, it occurs most often
during repeat doses and in pediatric use. Premedicate pediatric patients
(under five years old) with 0.15 to 0.20 mg/kg atropine to stabilize their
heart rate-essential for maintaining normal cardiac output.
Malignant hyperthermia: Some patients have a hereditary condition
known as malignant hyperthermia (MH) that places them at risk for a
severe metabolic syndrome when exposed to certain anesthetics, including
succinylcholine. MH is characterized by increased oxygen consumption,
significant heat production from increased muscle activity, respiratory and
metabolic acidosis and muscle rigidity. Eventual hyperthermia may exceed
110 F.
Signs of Malignant Hyperthermia:
Tachycardia (usually the first sign)
Increased CO2 (Hypercarbia) (exhibited by end-tidal CO2)
Decreased SpO2 (Hypoxemia) (exhibited by pulse oximetry)
Cardiac dysrhythmias
Hypertension
Skeletal muscle rigidity
Temperature elevation (usually a late sign) exhibited by increased skin
temperature and increasing oral or tympanic temperature.
ALERT: Neuromuscular blockers have no sedative or analgesic effects, so
patients will still feel pain and anxiety, and may remember everything that
happens to them, even though they appear to be asleep. It is crucial to
administer a medication such as Versed to sedate the patient prior to or in
conjunction with administration of a neuromuscular blocker.

Conquer Difficult Airways

MH Prevention
Currently, MH mortality is estimated at 10%, a significant decrease from
nearly 80% when it was first identified in 1960. Increased awareness
among health-care providers and improved care have caused this decline
in deaths. The best way to prevent MH is to detect those at risk prior to
administering succinylcholine. Inspect the patient for MedicAlert bracelets

and necklaces. Family history, although difficult to establish during an

emergency intubation, serves as a good predictor of MH. Any history of
death for one of the patient's family while under anesthesia should alert the
provider to the potential for MH.
Limit the prehospital treatment of MH to cooling and rapidly transporting
the patient to a hospital equipped to treat the crisis. Most hospitals stock
dantrolene sodium (Dantrium), the only medication known to effectively
treat MH. Notify the receiving hospital via radio while en route that you
suspect MH to give ED personnel adequate time to obtain the medication
from the pharmacy or operating room.
Anytime a paralytic such as succinylcholine is to be administered, you
should perform the Sellick maneuver to reduce gastric distention during
BVM ventilation and prevent passive regurgitation of stomach contents.

Conquer Difficult Airways

What if succinylcholine is contraindicated?
If you determine succinylcholine should be withheld, you can administer a
fast-acting nondepolarizing muscle relaxant, such as Rocuronium, with the
understanding that the onset of paralysis will occur more slowly and the
duration of paralysis will last longer.

Conquer Difficult Airways

Conclusion
Overall, the prehospital performance of RSI has proven safe. Most
complications relate to problems encountered in intubating paralyzed
patients with difficult anatomy and those who have adverse reactions to
succinylcholine. Advance knowledge of these factors will reduce the
overall complication of this procedure.

Conquer Difficult Airways

Review Checkpoints
Conscious patients who require invasive airway intervention may
powerfully resist the stimulation caused by insertion of a
laryngoscope blade and endotracheal (ET) tube. Body systems
respond to these noxious stimuli by elevating blood pressure,

increasing intracranial pressure, coughing forcefully and gagging. As

a result, intubation attempts often fail.
Rapid sequence intubation (RSI) is the simultaneous administration of a
sedative and muscle relaxant to facilitate ET intubation.
Today, prehospital use of RSI has increased, primarily due to its
effectiveness and relative safety for establishing adequate
oxygenation and ventilation for critical patients.
The powerful medication involved in RSI may cause harm if used
improperly or administered to the wrong patient.
Despite complications, succinylcholine remains the most commonly used
initial paralytic for prehospital RSI.
Once adequate relaxation is achieved with succinylcholine, the provider
can easily displace the tongue and mandible, visualize the glottis
and intubate the patient.
Administration of sedatives and muscle relaxants requires the EMS
provider to be thoroughly familiar with the indications,
contraindications and side effects of the medication, as well as
experts in airway management.
The most likely complications of RSI include an inability to intubate
because of difficult airway anatomy and adverse reactions to
succinylcholine.
Failure to recognize a difficult airway prior to induction with RSI may
result in an apneic patient who cannot be intubated conventionally.
If you determine that mask ventilation and laryngoscopy are difficult,
withhold administration of RSI medications and secure the alert
patients airway with traditional airway control methods.
Succinylcholine transiently increases pressure within the brain, stomach
and eyes. Thus, EMS providers should anticipate vomiting and
minimize the potential for aspiration.
Patients with increased intracranial pressure (ICP) often require airway
protection and controlled ventilation.
All patients who receive succinylcholine experience a slight increase in
their serum potassium, which isnt usually a clinical concern.
However, a small number of patients can have a much greater, lifethreatening potassium increase. These include patients with burns,
crush injuries, spinal cord injuries and extensive necrotic soft-tissue
infection.
The most significant complication of hyperkalemia is cardiac arrhythmias,

including complete heart block, ventricular fibrillation and asystole.

Earlier ECG signs include tall, peaked T waves, WRS widening and
flattening of the P wave. Patients may also complain of muscle
weakness, nausea, vomiting and diarrhea.
Some patients have a hereditary condition known as malignant
hyperthermia (MH) that places them at risk for a severe metabolic
syndrome when exposed to certain anesthetics, including
succinylcholine.
Currently, MH mortality is estimated at 10%, a significant decrease from
nearly 80% when it was first identified in 1960. The best way to
prevent MH is to detect those at risk prior to administering
succinylcholine. Inspect the patient for MedicAlert bracelets and
necklaces. Family history, although difficult to establish during an
emergency intubation, serves as a good predictor of MH.
Limit the prehospital treatment of MH to cooling and rapidly transporting
the patient to a hospital equipped to treat the crisis.
Notify the receiving hospital via radio while en route that you suspect MH
to give ED personnel adequate time to obtain the medication from
the pharmacy or operating room.
Test results for the lesson: ALS: Conquer Difficult Airways
Taken by: Edder Peralta on 3/29/2010 10:10:36 PM ET
Your score was: 95% The minimum passing score as set by your
training administrator is: 80%
To return to your lesson plan, click Personal Page from the
menu above. If you did not receive a passing score, click on the
lesson title to retake the test.
Test Results Summary

Answers shown in red are incorrect.

1. RSI is the simultaneous administration of a(n):
A. sedative and muscle relaxant
B. muscle relaxant and neuromuscular blocker
C. sedative and analgesic

D. anesthetic and sedative

Your incorrect answer: B

2. A mouth opening of 2 finger widths means:

A. visualization of the vocal cords is not possible
B. intubation should be easy
C. laryngoscopy may be difficult
D. nasal intubation is contraindicated
Your correct answer: C

3. Muscle fasciculations are:

A. a rare occurrence following sedation
B. a life-threatening reaction to a medication
C. an indication that a patient requires RSI
D. a known side effect of succinylcholine
Your correct answer: D

4. Hyperkalemia following succinylcholine administration:

A. occurs only in patients with heart disease
B. should be treated with sodium bicarbonate
C. is commonly seen as an immediate side effect
D. can be life-threatening for a burn patient
Your correct answer: D

5. Properties of succinylcholine that make its use ideal for RSI include:
A. long lasting effects
B. rapid onset
C. few serious side effect
D. does not cause fasciculations
Your correct answer: B

6. Muscle fasciculations can be prevented by administering:

A. high doses of succinylcholine
B. muscle relaxants without sedatives
C. medications IM instead of IV
D. a non-depolarizing paralytic
Your correct answer: D

7. The body responds to the stimulus of a laryngoscope inserted into the airw
A. decreasing blood pressure
B. increasing blood pressure
C. increasing airway secreations
D. decreasing airway secreations
Your correct answer: B

8. Fasiculations:
A. can be fatal
B. usually last less than 15 seconds
C. last for up to two hours
D. may cause hypoxia
Your correct answer: B

9. If you determine that a patient will be difficult to intubate, you should:

A. perform RSI
B. ventilate by other means
C. immediately perform a surgical airway
D. give sedation only with no muscle relaxants
Your correct answer: B

10. Which of the following would predict a difficult intubation?

A. thin person with long neck
B. a completely visible uvula
C. obese or pregnant patients
D. thyromental distance of 3 finger widths

Your correct answer: C

11. Which of the following is true of difficult airways?

A. About 25% of the population will be difficult to intubate
B. It's impossible to predict which patients will be difficult to intubate
C. Difficult airways can only be managed surgically
D. It's important to assess for a difficult airway prior to paralytic administratio
Your correct answer: D

12. Which of the following lung sounds indicates upper airway blockage?
A. rales
B. crackles
C. wheezes
D. stridor
Your correct answer: D

13. Succinylcholine is contraindicated in patients with:

A. increased intracranial pressure
B. vomiting
C. an intact gag reflex
D. penetrating eye injuries
Your correct answer: D

14. Field studies of RSI have shown:

A. only mild side effects occur
B. fatal consequences occur commonly
C. overall, RSI in the field is safe
D. RSI should only be used by air medical crews
Your correct answer: C

15. Succinylcholine can cause elevation in pressure in all of the following EXC
A. eyes

B. lungs
C. brain
D. stomach
Your correct answer: B

16. Hyperkalemia usually develops

A. in less than 10 seconds
B. over several minutes
C. in hours to days
D. over 30 days
Your correct answer: C

17. The most significant complication of hyperkalemia is:

A. cardiac arrhythmias
B. vomiting
C. increased ICP
D. constricted bronchioles
Your correct answer: A

18. Which of the following patients would be most likely to develop bradycar
A. pediatric patients
B. patients with cardiovascular disease
C. burn patients
D. hypoxic patients
Your correct answer: A

19. Which of the following is an indication of malignant hyperthermia?

A. hypocarbia
B. muscle relaxation
C. elevated temperature
D. hypotension
Your correct answer: C

20. Prehospital treatment for malignant hyperthermia is:

A. cooling and rapid transport
B. anti-convulsants
C. benzodiazepines
D. immediate intubation and hyperventilation
Your correct answer: A