Succinylcholine - Prehospital Abuse/Misuse

[Sugi]

I just want to be clear before posting this...

a) it is NOT ment to be offensive or bring any sort of disrespect to any one.
b) this is simply for a class discussion we are having, theoretical


I am currently working through my pharmacology class that is part of my paramedic program, and we were asked to start a discussion about certain topics. I chose to discuss RSI. Except here in Arizona, RSI is not a tool in toolset of a paramedic (except in Peoria), as Succinylcholine has been taken off (or not allowed in the first place) of all the rigs in the valley (again, except Peoria)

Speaking with an instructor who has been teaching medic students for the last... I believe 15 or 20 years, she said that the reason why we never had Succinylcholine is because, when this drug was introduced, paramedics from AZ went to parts of the country that were using Succinylcholine already, to try to get a feel for the drug, and its application, and had many many horror stories to tell..

Most of you should be familiar with Succinylcholine (and I refrain from referring to it as "sux" or "succs" per the advice and warning of said instructor, stating that this drug is dangerous enough that it demands respect, and should not be referred to in loose terms like "sux" or "succs"), however if you are not this drug is a paralytic. It is used when performing RSI.

Well, one of the things that was reported was that Succinylcholine was being used to essentially chemically restrain patients (drunk patients, mental disabilities, etc). So basically, because a patient was being unruly, or difficult, the attending paramedics were taking away this patients ability to breath.

Does anyone have any stories about these types of situations? I've contacted a few malpractice attorneys, and some medical directors in the area, however as Succinylcholine was not in the Phoenix valley (or only in the Phoenix valley for a short period of time, I'm not sure which), I was not able to pull up any situations like this.

 

[firecoins]

Sorry, never heard of "succs" being used to restrain drunks. Where did these paramedics go? The MDs would flip if it were used in any situation other than RSI. The abusing medics would be gone.

 

[1badassEMT-I]

All I can say is wow......they would do jail time here for sure..... as for WV CCT Medics are the only ones here that able to RSI and I have not heard them doing anything else with other than RSI. But succs is not on trucks here other than CCT trucks. Also very rare a CCT Medic administer it as that is done in the ER by a Doctor... And the CCT Medic maintains it...but can do if needed.

 

[SeeNoMore]

I think the issue is more proving whether pre hospital RSI is worth the risks. I have not heard of the issues you mention, but lots of dumb things get done so it would not really surprise me. Where I work, only flight medics use RSI.

 

[TransportJockey]

Back in NM I believe there was one ground service with RSI (other than a service I used to run with that had a couple of CCT trucks), the rest didn't have it. Flight teams were generally the ones with RSI.

 

[MrBrown]

Suxamethonium is a useful tool however, the evidence from our own prehospital RSI pilot program (since 2006) and provisional data from the Victorian RSI study shows it must be

- combined with adequate analgesia (we use ketamine and fentanyl) and
- restricted to a selected group of Intensive Care Paramedics and to patients who require it. The decision to use RSI or not is far more important than the psychomotor skill of administering the drugs.

We have consistently shown 95%+ success rates in our RSI program since 2006.

 

[usalsfyre]

I have never heard of sux misused in this way. Given inappropritely to difficult airways, yes, but not to abuse a patient.

Sux is a nasty drug, even for it's intended purpose however. Many side effects including hyperkalemia, malignant hyperthermia, ect. There are better paralytic choices out there.

 

[reaper]

I have used it in RSI for years and have never seen nor heard of it being used in any way outside of RSI, in prehospital.

RSI should only be used by educated and trained medics. As stated, it is not the use of it, it is the use of it at the wrong time. You must be educated on how to rate a pt for airway, prior to even thinking about RSI.

I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.

 

[medic417]

Perhaps they got confused with the sedative being used that is listed on the services RSI protocol. Often the same sedative such as versed is used to chemically restrain people and for sedation for RSI.

That or they have read some the idiotic practical joke threads on here where people laugh about hurting people so they decided it is ok to do so.

 

[Aidey]

I've never heard of succs being used that way in real life. I've heard jokes made, and made them myself, but nothing realistic and nothing that was meant as a serious "I would do this" statement. I'm pretty sure our medical director would consider literally stick your head on a pole if that really happened.

I wondered the same thing about the people mixing up* the sedative and paralytic since some places do have chemical restraint protocols. We do; using versed, but none of the other RSI drugs.

*Not mixing up when they were administered, but mixing up when repeating the story.

Ok, I just had to eat my words, because right after I posted this I saw the link in the "Similar threads" box to the news report I posted on succs being used to assassinate a Hamas leader. So I rephrase, and say that I have never heard of it being used in EMS in such an inappropriate manner.

Succs has it's benefits. I do wish that after we successfully intubated the pt using succs we were able to give a longer acting med. We do have Vec, but the problem we run into is that most of our transports are too short to fall into the Vec protocol, but succs isn't long enough when you add transport + hand off time + waiting for Respiratory to get there with more meds. I know from talking with docs in the ER they like it when we use Vec, and several have mentioned Rocuronium (sp?) as another one they would be happy with us using.

 

[Flight-LP]

I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.

I completely disagree respectfully, I absolutely despise Anectine and refuse to use it. The depolarizing effects and extracellular potassium shift isn't worth the additional aggrevation that it can produce. I prefer Zemeron or will just induce with Ketamine, Propofol, or Etomidate (whichever I have immediately available). Far less issues all around for a patient who is already compromised.

 

[usalsfyre]

I have used it in RSI for years and have never seen nor heard of it being used in any way outside of RSI, in prehospital.

RSI should only be used by educated and trained medics. As stated, it is not the use of it, it is the use of it at the wrong time. You must be educated on how to rate a pt for airway, prior to even thinking about RSI.

I truly believe that it is the best drug of choice for initial Paralytic. It is a short acting drug, which makes the side effects worth the risk. If you can not get the pt intubated, they can be assisted until it wears off. It normally only lasts 10 minutes. Most other paralytics on the market last from 30 minutes or longer. That is not what you want, if the airway is failed.

The "I can just bag them till it wears off" theroy is DANGEROUSLY flawed. If you have a patient whom airway success is in any serious dobut, you shouldn't be using a paralytic, period. If the pt can't be intubated, a EGD won't work and a crich is contraindicated, do you really expect to be able to bag them? If you don't have appropriate backup devices, you have no business doing RSI, and your medical director is negligent. You can't half-@$$ this procedure, if you wanna play, you gotta pay.

Sux was the choice for a longtime due to rapid onset, not short duration. However, non-depolarizers with a similar rapid onset have come along with a much better side effect profile.

Flight-LP, I agree, rocc is the bee's knees. Recently switched to it from sux and haven't looked back.

 

[reaper]

The "I can just bag them till it wears off" theroy is DANGEROUSLY flawed. If you have a patient whom airway success is in any serious dobut, you shouldn't be using a paralytic, period. If the pt can't be intubated, a EGD won't work and a crich is contraindicated, do you really expect to be able to bag them? If you don't have appropriate backup devices, you have no business doing RSI, and your medical director is negligent. You can't half-@$$ this procedure, if you wanna play, you gotta pay.

Never said, bag em till it wears off! But yes, it can work and does. Did you skip over the part of rating an airway, prior to even considering RSI? There are times that you will not get them intubated, after RSI, even with everything perfect. You damn well better know how to deal with this situation before hand.

Sux was the choice for a longtime due to rapid onset, not short duration. However, non-depolarizers with a similar rapid onset have come along with a much better side effect profile.

No, we carried it solely due to short duration. Rocc has rapid onset, but duration of 45 minutes. We carry both, but prefer Succs as initiator, then we back up with Rocc. Always expect the unexpected.

Flight-LP, I agree, rocc is the bee's knees. Recently switched to it from sux and haven't looked back.

Rocc is a great drug and have carried it for years. We still carry both, as they have their place.

Anyone that preforms RSI, should be well trained and educated in it's use and contraindications. We have a very high success rate, due to quality education and frequent airway training.

 

[usalsfyre]

Reaper, I hve been doing RSI for many years as well, and have been to numerous classes on it. For the last 2 years I have consistently been doing 1-2 a month, so I've got a fair bit of exposure to the procedure. I am very familiar with the LEMON assesment and how to use it. I stand by what I said. If you are carrying sux for it's short duration, you're carrying it for the wrong reason.

You are exactly right, if you end up in a failed airway, you better have a back up plan sooner rather than later. Trying to BVM an obese, bearded short necked COPD and CHF patient with a receding chin for the 7-12 minutes before the paralytic STARTS to wear off (you don't get complete reversal at that point) will likely not have a good outcome. Does your service have an alternative for predicted difficult airways? For instance NTI or etomidate only attempts?

 

[reaper]

Reaper, I hve been doing RSI for many years as well, and have been to numerous classes on it. For the last 2 years I have consistently been doing 1-2 a month, so I've got a fair bit of exposure to the procedure. I am very familiar with the LEMON assesment and how to use it. I stand by what I said. If you are carrying sux for it's short duration, you're carrying it for the wrong reason.

You are exactly right, if you end up in a failed airway, you better have a back up plan sooner rather than later. Trying to BVM an obese, bearded short necked COPD and CHF patient with a receding chin for the 7-12 minutes before the paralytic STARTS to wear off (you don't get complete reversal at that point) will likely not have a good outcome. Does your service have an alternative for predicted difficult airways? For instance NTI or etomidate only attempts?

Yes, we carry NTI and Etomidate. Both are useless in a failed RSI. That is what I am talking about. You may have not had one happen yet, but it will. I have used a BVM to assist a Pt, until they were on their own. Yes, it is hard, but works fine, if done correctly. We carry succs for our own reasons, who are you to say it is the wrong reason? I am not arguing RSI with you. I am trying to let people know that they must be prepared to deal with the downfalls. They do happen.

 

[mycrofft]

Sux blowdarts...

Like the old "...so I had to hit him with the E cylinder", it's part BS, and maybe a little life imitating braggadocio. A better subject would be "The Propagation Of Cultural Mores and Shibboleths Between EMS Workers Via Mythology".

 

[Sugi]

So the general consensus is that

1. No ones ever heard of this type of misuse or abuse of a paralytic
and
2. If it were to happen, the medic in charge would be hung out to dry pretty quick.


Thats interesting... Im not sure how long ago the stories were from, so I definitely want to check back on that.

I appreciate all the input guys!

 

[usalsfyre]

Yes, we carry NTI and Etomidate. Both are useless in a failed RSI. That is what I am talking about. You may have not had one happen yet, but it will. I have used a BVM to assist a Pt, until they were on their own. Yes, it is hard, but works fine, if done correctly. We carry succs for our own reasons, who are you to say it is the wrong reason? I am not arguing RSI with you. I am trying to let people know that they must be prepared to deal with the downfalls. They do happen.

Reaper, I will agree to disagree with you on carrying sux.

The bigger point I'm trying to hit is if you don't think you can intubate DON'T PUSH DRUGS THAT INTERFERE WITH THE PATIENTS ABILITY TO BREATHE!!!!! If your looking at a patient with a poor LEMON assesment, you must have realistic options besides a full RSI sequence. For instance non-paralytic DAI, video laryengoscopy and NTI. In addition have real backups such as Combi/Kings and surgical crichothrotomy. A BVM and a prayer is not a backup, not to mention you still end up with an unsecured airway. But most importantly have the training to know when the clinical benefits of taking someones airway in an asture environment (compared to an OR) with a limited amount of help and resources far outweighs the risk.

I have been involved in two failed RSIs. Looking back, with the experince and knowledge I have now, neither one of those patients should have been RSI'd with a paralytic. Both were cases of too little knowledge and too much agression.

 

[Melbourne MICA]

Nasty

Sux - it's like a New Zealander saying six. (No offence to my cousins across the Tasman intended. PS the all whites were brilliant!!!).

But six is the magic number. Six feet under for the pt if you mess with this little drug number and six steps to the front door of your branch if you think it's a cute toy with a cute name and treat it with anything but respect.

As for being used or useful to manage rowdy pts - ask the South American Indians who liked using paralytics on their blow dart tips just before they sliced off your head.

Paralytics are NEVER used without sedation and analgesia.

We use Suxamethonium and Pancuronium with Midazolam and Fentanyl (Morph) in our RSI protocol.

MM

PPS To MYCROFT - Twaz brillig and the slithy toads did gyre and gimble in the wade, all mimsy were the borrogroves and the mome raths outgrabe. "I don't think we are in Kansas anymore Toto".

 

[MrBrown]

Sux - it's like a New Zealander saying six. (No offence to my cousins across the Tasman intended. PS the all whites were brilliant!!!).

Yeah, but we don't have Ronaldo .... so no wonder we are now out of the World Cup. I must say we have spent a fair amount of time infront of the telly at work watching the highlights of Ronaldo hmmmmmmm

We use Suxamethonium and Pancuronium with Midazolam and Fentanyl (Morph) in our RSI protocol.

How much midaz are you using? I am not so much concerned about the 1mg or so you give somebody who is traumatically brain injured with a GCS of 3 vs the amount you are going to have to pour into that catatonic asthmatic who is still conscious so he won't remember.

We used to use midazolam but now we use 1.5mg/kg of ketamine (unless the patient is traumatically brain injured or has neurogenic cause for coma with GCS < 10)

Mind you I am no anaesthetics consultant (one day......) but I hear that midazolam is great for wrecking people's blood pressure and other nasty things when given in any significant dose.

Although you are using sux too so it's probably only a small dose to give amnestic effect rather than any serious neuromusclar relaxation.

*Brown goes back to reading his anaesthesia textbook in an effort to obtain more knowledge