Masseter spasm after succinylcholine administration

Pharmacotherapy optimization for rapid sequence intubation in the emergency department

PURPOSE

Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods.

SUMMARY

There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use.

AREAS FOR FUTURE RESEARCH

The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Controversies in Pediatric Perioperative Airways

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

Masseter muscle rigidity: Atypical malignant hyperthermia presentation or isolated event?

This report describes a case of masseter muscle rigidity encountered at the start of an elective gynaecological procedure. At preoperative assessment, the patient, a 41-year old woman with a previous non-eventful surgical and anesthetic history was given a Mallampati score of 3. Following suxamethonium administration, full mouth opening proved difficult. Laryngoscopy and tracheal intubation were not possible leading to the eventual use of a laryngeal mask airway and resulting in a successful anaesthetic outcome. A number of possibilities that may account for this situation as well as viable options for airway access in such cases are discussed below.

Succinylcholine-Induced Masseter Muscle Rigidity in an Emergency Department: A Case Report

Succinylcholine is the most popular muscle relaxant employed in local accident and emergency departments because of its effectiveness and short-acting half life. Significant adverse reaction is rare and it increases the success rate of intubation. We describe a case of masseter muscle rigidity after administration of succinylcholine alone in the emergency room. The patient subsequently required nasotracheal intubation for ventilation.

Challenges and advances in intubation: rapid sequence intubation

Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.