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Three Part Question

In [peri-arrest patients] is [suxamethonium as sole intubating agent] less likely to [induce cardiac arrest, than with use of additional agents]?

Clinical Scenario

You are the emergency department (ED) duty doctor for resus, and get a pre-alert from the ambulance service about a patient with massive haemorrhage from a groin gunshot wound whilst eating in a fast food shop, ETA 5 minutes. RR30, HR 55, NIBP 40/palp, GCS of 5 with E1 V2 M2, no other vital signs given. Having placed a trauma call and activated the major haemorrhage protocol, rapid sequence intubation drugs are being drawn up.

You note the last time a patient similar to this attended in a peri-arrest state, they arrested at induction despite markedly reduced doses of ketamine, keeping with your concerns about a patient who has used up most of their endogenous catecholamine stores. Etomidate isn’t stocked, and you wonder if faced with the same situation, and if you can’t improve haemodynamics more, whether you would consider a suxamethonium-only (with the intent of induction and maintenance of anaesthesia after endotracheal tube secured) intubation?

Search Strategy

CINAHL, EMBASE, Medline were searched, with no limitation on date or language, via the NICE Healthcare Databases Advanced Search portal (search strategy: 451951).
ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry, PROSPERO and TRIP were searched with a simpler search string.

494 search results for "(sux OR suxamet* OR succinylch* OR scoline OR anectine).ti AND (only OR sole OR single OR lone)" as of 20th June 2018

CINAHL: 31
EMBASE: 287
Medline: 176

ClinicalTrials.gov: 26 results
ANZCTR: 6 results
PROSPERO: 2 results
TRIP: No relevant results not already identified in HDAS strategy

Search Outcome

Total: 494 results, with 177 duplicated. After removal of these, 316 articles screened based on title or abstract with regard to the three part question using the Rayyan free open access platform(1), with no results directly relevant to the proposed three part question. 16 results discussed the known issues related to suxamethonium and induction of arrest or massive adverse signs, especially in those with muschular dystrophies and in children.

No other relevant results from the other four resources aforementioned.

Comment(s)

The concept of suxamethonium only intubation in the peri-arrest patient has not been directly addressed or reported from the literature search performed. Admittedly this is a concept that is influenced by publication bias, given that these patients who may well have died as a result from a number of factors are not reported as a case or series. Whilst not identified in the literature search, it may form a caveat or side note in the grey literature such as Standard Operating Procedures (SOPs) of those organisations which are likely to encounter such peri-arrest patients such as Helicopter Emergency Medical Services, Enhanced Care Teams and Pre Hospital Clinicians who administer muscle relaxants.

Clinical Bottom Line

This is an evidence poor area. Given the grave circumstances of some patients, suxamethonium only intubation could be considered where the clinician feels the use of any other additional drugs is more likely to push the patient into cardiac arrest than the former option. The risk of awareness may be ameliorated by the low cardiac output and cerebral perfusion state such peri-arrest patients are in. The humanitarian requirements of induction agents require balancing with risk of cardiac arrest by the clinician in charge and treating team (Grade D recommendation). References 1. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev [Internet]. 2016;5(1):1–10. Available from: http://dx.doi.org/10.1186/s13643-016-0384-4