When it sucks to use sux

[BushyFromOz]

Cool thread title eh?

Okay, now, i realise im shairing homework and its usually frowned upon (yeah, im looking at you paramedicmike =D) but rest assured this is not about trying to get free answers, im just interested in what other peoples thought on this would be.

Basically its a 30 y/o M, heroine OD who has aspirated and been in a feotal posion up against a cupboard for several hours. HR170, B/P 60/40, GCS 5, Temp 37.9, RR 18 with fine exp. crackles, SP02 of 88% despite being oxygenated with 100% 02 and an ECG showing sinus tach with triplets of VEB's. You have not seen anything that indicates hyperkalaemia or rhabdomyolysis either ECG or physical finding but you lecturer is a sadist who likes to arm you with a bunch of readings about the association of drug overdose and rhabomyolysis to complicate your thinking before cooking up a scenario like this to test you out.

Now i have already elected to go softly softly on the fluid because of the aspiration possibly neurogenic APO?? and unless there is a significant change in theri heart rate with 02 and fluid adrenaline is pretty much out of the question, but i still need to intubate him.

The question is, would using suxamethonium with its hyperkalaemia contrindication be too much of a risk, considering you cant find a physical or ECG finding to back up your suspicion, other than the fact the patient has been hypotensive and immobile for several hours placing him at risk of rhabdo?

I'll finish this off by saying that i also have sedate to intubate at my disposal (and it is what i have elected to proceed with)

[1EMT-P]

I would avoid the use of Sux in thie patient and here is why. One of the side effects of Sux is hyperkalemia which is caused because acetylcholine receptor has been propped open allowing potassium ions to move into the extra cellular fluid. If you are concerned about your patient suffering " muscle and tissue damage" then you might want to avoid Sux. Personally I would consider going with supportive care including blind nasal intubation or BVM with a nasal airway.

[chbare]

I would be cautious about using Sux in this patient based on the history alone. ECG findings are often not as telling as you may be lead to believe. This patient is also at incredible risk for haemodynamic complications based on the blood pressure, heart rate and the Oxygen saturation. I would be very cautious about proceeding with RSI at this time. Can we see about giving fluids? I understand you have some concern, but intubating with such a terrible pressure is a potential death sentence.

[paramedicmike]

I don't know, mate. Give this patient a few more minutes and you just might have a crash airway on your hands. You wouldn't have to worry about sux at that point.

I, too, would not use sux in this patient. Given what you've presented I would go with a sedative only attempt.

The above noted concerns about intubating this patient given the pressure are valid. However, I think in the scenario you've presented you're damned if you do and damned if you don't. Much of the decision to intubate would be made after a thorough airway assessment and evaluating just how confident I would be getting a quick tube and not having to muck around in his airway.

And come on. I've been good lately. I'm mellowing a bit in my old age.

[chbare]

http://emcrit.org/podcasts/intubation-patient-shock/

I think this is a particularly relevant podcast. If the pressure is to believed , you may very well kill this patient during the procedure.

[BushyFromOz]

thanks for the replies.

What i would really like to say is fluid load him cautiously and oxygenate him for 10 minutes and see where we are at with his CVS signs, but i only get one set of obs to work with.

I had forgotten about those podcast's from weingart, so im going to listen to them again. thanks chbare

Mike, i think the whole point of this one is entirely because it is a dammed if you do / dammed if you dont, They put a transport time of 1+ hours in and no air support.

I do not believe that i ever thought doing ICP would be easy, but im still shocked at how much more complicated and difficult the decision making is. If i ever hear someone say that its just some extra drugs, guidelines and skills i think im going to slap someone!

[Kiwiology]

Bah! Flimshaw! Balance of risk vs benefit is in favour of not using suxamethonium.

I'd use vec or roc, I forget which it is you carry but I'd just use that.

IFS is IMO bad ju ju so I wouldn't be using that.

[rock_shoes]

Bag him up and do a little fluid loading at the very least. If you have a push pressor at your disposal (say phenylephrine) now is probably the time to give it a go (fill the tank, shrink the tank). The tachycardia is more hypoxia/hypotension than anything so working on those two issues should largely solve the tachycardia.

When the time comes to actually intubate hopefully you've been able to pre-oxygenate a little better than you were doing passively with a mask. I'm on board with kiwi regarding paralytics. Go non-depolarizing and skirt the issue altogether (rocuronium or whatever you happen to carry). Are you blokes in the deep south carrying suggamadex yet? I'm assuming ketamine is your first choice for sedation in the land of Oz. If you're still worried about using paralytics at all you could always go super old school and hose down the airway with lidocaine spray. The lidocaine spray seems ridiculous but it works in a pinch.

[BushyFromOz]

Rock shoes: for some reason we only have adrenaline as a pressor, though im told Norad is getting another look in. Thanks for the rest of the advice.

Kiwi :

Fentanyl / midazolam / sux / tube pancuronium for RSI

Fentanyl / MIdaz / tube / Panc = IFS

Ketamine for induction in the next few months, but the fent / midaz will remain for TBI kiwi.

Mike: Are you saying your getting old?

Bah! Flimshaw! Balance of risk vs benefit is in favour of not using suxamethonium.

See, that's what i needed, the simple answer instead of all this other complicated crap clouding my judgement.

Medical standards says IFS ok for select patients, who am i to argue with The Alfred hospital kiwi =D

[Kiwiology]

Just because Mark Fitzgerald et al say something doesn't make it right or applicable in every situation; personal opinion only but I don't really think IFS is appropriate. RSI or go home.

We have significantly increased our dosing of fentanyl and midazolam in RSI such that a standard patient gets 150 mcg of fentanyl and 6 mg of midazolam.

Ketamine (100 mg) is used for patients who have shock.

I would much prefer ketamine for everybody; midazolam is a poor choice of anaesthetic and no anaesthetist in their daily practice would use it for induction routinely.

I should be seeing the Medical Director next week so I might ask why they have chosen this.

Edited March 10, 2014 by Kiwiology