Rapid Sequence Intubation
Although controversial, many physicians are concerned with succinylcholine-induced hyperkalemia. Succinylcholine results in skeletal muscle cell depolarization, causing an intracellular potassium efflux and subsequent neuromuscular blockade. Recent literature found that this efflux results in a mean potassium increase of 0.4 mEq/L, usually occurring a few minutes after administering succinylcholine.69 Often, this increase is transient and without clinical impact, but cases have described sudden death following the administration of succinylcholine. Patients with upper or lower motor neuron defects, prolonged chemical denervation, direct muscle trauma (crush injury), thermal trauma, disuse atrophy, and severe infection have all been linked to an increased risk of hyperkalemia following rapid sequence intubation with succinylcholine. If there is a high clinical suspicion of hyperkalemia either by history or from an ECG suggesting associated changes, alternative paralytics should be used for rapid sequence intubation.
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