A brand-new CCT senior is notified by EMS triage, the attending, the bat phone, his junior, the nurse, the PCA and the stocking people that he should probably intubate his patient- the 38-year-old patient with sickle cell disease with ESRD on hemodialysis who presents weird and vomiting and is found to have a large intracranial hemorrhage. After the group stops yelling at the panicked “senior”, he meekly calls for etomidate and succinylcholine as his RSI medications. The group (now including the UCG-performing PCT) collectively gasps. What are the side-effects of succinylcholine and why is it the wrong choice for this patient?
AnswerKnown side effects of succinylcholine are increased ICP/intraocular pressure, fasciculations, malignant hyperthermia, and the dreaded…..hyperkalemia. This hyperkalemia is concerning for certain “at-risk” patients. These are patients with kidney disease (like our patient), crush injuries, burn injuries, multiple trauma, neuromuscular diseases (ALS/muscular dystrophy), denervated skeletal muscle (strokes, spinal cord injury <6 months old), and abdominal sepsis. Our patient has ESRD and is dialysis dependent meaning that he likely ALREADY has hyperkalemia. Avoid dysrrhythmias due to hyper-K. Know when to hold the succ and try rocuronium instead.
By Sally Bogoch and Andrew Grock
Reference: Rivers
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1 Comment
andygrock · August 6, 2014 at 10:24 am
Great post Sally. Two quick points from a peanut gallery, 1. succ can cause hyperkalemia – so definitely don’t give it if someone is already hyperkalemic. Per pier 8, the only true contra-indication to succinylcholine is………………………Myesthenia Gravis…? Turns out people with MG make more acetylcholine receptors as a feedback mechanism making them overly sensitive to succinylcholine. I’ve never seen this in any other source and think it is definitely worth remembering as it will probably be clinically applicable moderately infrequently.
Cheers,
andy grock