# Succinylcholine and bath salts



## dogboy (Jun 10, 2011)

Pt at the ER the other day was high as a kite on bath salts with an elevated temperature of 103 to 104.  She got to the point where the ER doc wanted to intubate her.  He did not use succinylcholine and explained that it was contraindicated due to the hyperthermia from the bath salts.  He used high doses of versed.  Does anyone have any info on this?  I know it is contraindicated in malignant hyperthermia from genetic predisposition.  Bath salts are fairly new for us to deal with and if sux is contraindicated we need to know and address it.


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## Smash (Jun 10, 2011)

dogboy said:


> Pt at the ER the other day was high as a kite on bath salts with an elevated temperature of 103 to 104.  She got to the point where the ER doc wanted to intubate her.  He did not use succinylcholine and explained that it was contraindicated due to the hyperthermia from the bath salts.  He used high doses of versed.  Does anyone have any info on this?  I know it is contraindicated in malignant hyperthermia from genetic predisposition.  Bath salts are fairly new for us to deal with and if sux is contraindicated we need to know and address it.



What exactly do you mean by bath salts?

Barring knowing what is in these salts that may interact with sux, if pt has hyperpyrexia for a prolonged time there is risk of rhabdomyolysis, which would make sux a risky proposition.  Versed only certainly isn't what I would do though, why not use rocuronium and give the best chance of intubating?


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## usalsfyre (Jun 10, 2011)

Smash said:


> What exactly do you mean by bath salts?


"Bath salts" are our latest "legal" drug rage here in the States. Somewhere along the line someone figured out if ingested (usually snorted if I'm not mistaken) they're a hallucinogenic/stimulant. Why someone decided to snort bath salts, I don't know, but because there's not a specific prohibition against them, the younger populous is thrilled there's a "legal" high (that can kill you, but that's beside the point). Effects, from a brief wikipedia search, appear to be similar to cocaine or amphetamines. Not something we've seen a lot of here yet (K2 and synthetic canabis has been our designer drug) so I'm not real studied on it. 



Smash said:


> Barring knowing what is in these salts that may interact with sux, if pt has hyperpyrexia for a prolonged time there is risk of rhabdomyolysis, which would make sux a risky proposition.  Versed only certainly isn't what I would do though, why not use rocuronium and give the best chance of intubating?


Hyperkalemia and rhabdo is certainly a concern here. The other thing I thought about with sux was the potential to make the hyperthermia that much worse simply through the depolarization process, no MH pathway needed. As far as rocuronium....I don't know why we're not using it in place of succinylcholine period. Virtually the same onset, VASTLY better side effect profile and it get's people to truly put together an airway management plan rather than "we'll just bag'em till it wears off.


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## jwk (Jun 10, 2011)

A patient with a fever is not a contraindication to using succinylcholine.  We still use it routinely on febrile patients in the OR.  It's still the preferred drug for RSI, which is the reason that, despite the infrequent but occasionally significant risks, it's still in widespread use.  Research with ultra-short acting non-depolarizing drugs has been disappointing and no such drug has been brought to market yet.  Roc is the best alternative, but even in higher doses, still takes longer than sux.  And although rare, a can't intubate/can't ventilate scenario after roc only leaves you with one alternative.


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## usalsfyre (Jun 10, 2011)

jwk said:


> And although rare, a can't intubate/can't ventilate scenario after roc only leaves you with one alternative.



I was thinking (and have always been taught) a true can't intubate/can't ventilate  scenario ends with a scalpel no matter what agent was used, as 5-7 minutes of hypoxia will cause an unacceptable amount of physiologic damage. Am I missing something?


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## crazycajun (Jun 10, 2011)

The main ingredient in "Bath Salts" is methylenedioxypyrovalerone (MDVP) the best treatment is an anti-anxiety medication such as Valium, Xanax, Versed, etc. Because some street chemist have derived a new version of pyrovalerone Sux has been shown to be ineffective in treatment and has caused cardiac arrest in some PT's. Rocuronium has been found to bottom out BP and possibly stop the heart when introduced to high levels of MDVP.


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## jwk (Jun 10, 2011)

usalsfyre said:


> I was thinking (and have always been taught) a true can't intubate/can't ventilate  scenario ends with a scalpel no matter what agent was used, as 5-7 minutes of hypoxia will cause an unacceptable amount of physiologic damage. Am I missing something?



No, you're correct - but in most patients, sux will be wearing off in less than 5 minutes.  However, the pucker factor is extremely high in these situations, and you can only watch the SaO2 values on the floor for so long before ya gotta do something.  And, I'm guessing you're not likely to have all the toys I have in the OR in the field with you    so you play the cards you're dealt and do the best you can.


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## Smash (Jun 11, 2011)

jwk said:


> A patient with a fever is not a contraindication to using succinylcholine.  We still use it routinely on febrile patients in the OR.  It's still the preferred drug for RSI, which is the reason that, despite the infrequent but occasionally significant risks, it's still in widespread use.  Research with ultra-short acting non-depolarizing drugs has been disappointing and no such drug has been brought to market yet.  Roc is the best alternative, but even in higher doses, still takes longer than sux.  And although rare, a can't intubate/can't ventilate scenario after roc only leaves you with one alternative.



I've also used sux many times on febrile patients, but in replying to the scenario given and the comments made by the doctor I assume that this is not just a patient with a fever.  There is surely a difference between patient with a UTI and fever and someone jacked up on speed like substances with prolonged pyrexia and a much higher risk of rhabdomyolysis.  Given this scenario, I would still be using Roc.



jwk said:


> No, you're correct - but in most patients, sux will be wearing off in less than 5 minutes.  However, the pucker factor is extremely high in these situations, and you can only watch the SaO2 values on the floor for so long before ya gotta do something.  And, I'm guessing you're not likely to have all the toys I have in the OR in the field with you    so you play the cards you're dealt and do the best you can.



I was of the impression that the myth of safe apnea with sux is disappearing. 

_Tang L, Li S, Huang S, Ma H, Wang Z Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand. 2011 Feb;55(2)

Taha SK, El-Khatib MF, Baraka AS, Haidar YA, Abdallah FW, Zbeidy RA, Siddik-Sayyid SM.  Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction.  Anaesthesia. 2010 Apr;65(4):

Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.  Anesthesiology. 1997 Oct;87(4):979-82

Heier T, Feiner JR, Lin J, Brown R, Caldwell JE.  Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.  Anesthesiology. 2001 May;94(5):754-9

Naguib M, Samarkandi AH, Abdullah K, Riad W, Alharby SW. Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients.  Anesthesiology. 2005 Jan;102(1):35-40_

Rocuronium at 1.2mg/kg also gives essentially the same intubating conditions in the same amount of time as sux:

_Patanwala AE, Stahle SA, Sakles JC, Erstad BL.  Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department.  Acad Emerg Med. 2011 Jan;18(1):10-4

Perry JJ, Lee JS, Sillberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2008, Issue 2_



crazycajun said:


> The main ingredient in "Bath Salts" is methylenedioxypyrovalerone (MDVP) the best treatment is an anti-anxiety medication such as Valium, Xanax, Versed, etc. Because some street chemist have derived a new version of pyrovalerone Sux has been shown to be ineffective in treatment and has caused cardiac arrest in some PT's. Rocuronium has been found to bottom out BP and possibly stop the heart when introduced to high levels of MDVP.



Interesting.  Can you supply some references for these statements, my google-fu is failing me.


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## WTEngel (Jun 11, 2011)

Not to hijack, but a few thoughts on Succ and the mentality behind its use.

If you decide to perform RSI, then your patient is in extremis, and likely deteriorating or fixing to deteriorate. With that in mind, using Succ because you want the paralytic to wear off quickly in the event you are unable to intubate is a bit flawed in my opinion.

The patient is already in extremis, so the paralytic wearing off is not going to magically save us from the failed intubation scenario. In fact, in my experience, it muddies the water, because now you have to add to the failed intubation the need to re administer meds, wait for them to take effect, etc. 

In addition to this, I have found that Succ has a tendency to wear off exactly when you do not need it to. Such as when you pass the tube and are in the process of securing, or after you have secured and are re grouping for your next treatment. Having a patient begin to buck and come unglued is unpleasant at any time, however at critical moments, it can make or break the entire call. 

Essentially I am saying that if you decide to RSI, you need the tube whether the paralytic wears off or not. Having the paralytic wears off just adds to an already long list of problems in my opinion.

Now, on topic. If bath salts could lead to any renal insufficiency, or otherwise cause hyperkalemia, then Succ is a bad choice. The science is pretty clear on that. 

Patients susceptible to malignant hyperthermia for any reason should generally not get Succ as it can exacerbate this, or in some cases directly lead to it. 

I avoid Succ usage when treating my patients. I have had medical directors who have shared the same opinion, so I have never been forced to use it initially and then switch to a longer acting agent. That is why it is nice to have guidelines that allow for flexibility based on provider choice and patient presentation.


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## Smash (Jun 11, 2011)

I agree WTEngel: in the field if you think that you can just wait for your patient to start breathing and all will be fine, one has to question why you are doing an RSI in the first place. Especially since the evidence is increasingly against this idea anyway.


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## usalsfyre (Jun 11, 2011)

Smash said:


> I agree WTEngel: in the field if you think that you can just wait for your patient to start breathing and all will be fine, one has to question why you are doing an RSI in the first place. Especially since the evidence is increasingly against this idea anyway.


Agreed as well. If we're using medications to facilitate passing a tube, there better be a good reason. All that waiting for sux to "wear off" does is put several minutes further down the road in the bad situation you were already in. 

Used sux extensively, now use rocc exclusively. Can't say I miss sux in any way.


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## Smash (Jun 11, 2011)

I haven't had a bad run with sux, which is lucky as it is the only choice I have. I've thus far always managed to have tube in and secured plus further sedation +/- long term paralysis before it wears off. 
This is partly due to the fact that I am careful about who I give the scary drugs to, but mostly dumb luck I suspect!

I wish I could have roc as well (and ketamine) but the wheels turn veeeeeeeery slowly.


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## jwk (Jun 11, 2011)

usalsfyre said:


> Agreed as well. If we're using medications to facilitate passing a tube, there better be a good reason. All that waiting for sux to "wear off" does is put several minutes further down the road in the bad situation you were already in.
> 
> Used sux extensively, now use rocc exclusively. Can't say I miss sux in any way.



My perspective will of course be somewhat different since I'm doing all my work in the OR, not in the field, so I have some luxuries you won't have.  Most of my patients are breathing just fine when I first see them - most of yours are not.  

I use roc for RSI's all the time, but still use sux as well, both for RSI's and shorter procedures.  However, I still use sux on ANY anticipated difficult airways, because I don't want to burn any bridges by using roc or vec.  On the ever-so-remote chance I can't intubate/can't ventilate, chances are they'll start breathing again if I've used sux.  Once I've given roc (until sugammedex is available in the US) my patient will not be breathing anytime soon.  One of the options in the ASA Difficult Airway Algorithm is "consider awakening the patient" and allowing them to resume spontaneous respirations.  Using roc/vec takes away that option.  Again, I realize you may not have that option or consideration in the field if your patient doesn't have an airway or is apneic, in which case you probably don't need any drugs at all.


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## Smash (Jun 11, 2011)

jwk said:


> On the ever-so-remote chance I can't intubate/can't ventilate, chances are they'll start breathing again if I've used sux.



But all the evidence points towards that chance being too late, with critical desaturation already having occurred so the damage is already done by the time the sux wears off.


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## jwk (Jun 11, 2011)

Smash said:


> But all the evidence points towards that chance being too late, with critical desaturation already having occurred so the damage is already done by the time the sux wears off.



A couple things work in my favor, again because I'm in the OR and not in the field.  One, I will have pre-oxygenated these patients for several minutes to buy more time.  And, there's a difference between desaturation and when damage is actually being done.  Five minutes of apnea is not the same as five minutes of no circulation.


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## usalsfyre (Jun 11, 2011)

jwk said:


> My perspective will of course be somewhat different since I'm doing all my work in the OR, not in the field, so I have some luxuries you won't have.  Most of my patients are breathing just fine when I first see them - most of yours are not.


I think this is the big difference in day-to-day theater-based airway management vs. out of theater (and especially prehospital). The patients I'm RSI'ing absolutely need a)positive pressure ventilation or b)airway protection. As such, if we end up in a CICV situation the patient is probably better off getting a cric, as opposed going back needing airway protection/PPV. On the other hand, go in for a routine knee arthroscopy and wake up with a hole in your neck...well, people tend to get pissy.




jwk said:


> One of the options in the ASA Difficult Airway Algorithm is "consider awakening the patient".


In the truly difficult airway, I've been leaning more and more towards doing them awake with topicals than putting them out at all. This is, of course, with the blessing of my medical director and clinical services department.


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## usalsfyre (Jun 11, 2011)

jwk said:


> A couple things work in my favor, again because I'm in the OR and not in the field.  One, I will have pre-oxygenated these patients for several minutes to buy more time.  And, there's a difference between desaturation and when damage is actually being done.  Five minutes of apnea is not the same as five minutes of no circulation.



We do a lot of preoxygenation, but I do have to ask (cause I've never gotten a satisfactory answer), when is damage being done? A low sat is not a death sentence, but obviously your looking all other sorts if badness eventually. Is bradycardia a good indicator? And what do you think of Dr Leviathan's nasal oxygen insulflation technique?


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