High Alert Medication

Depolarizing neuromuscular blocking agent

CCP: Paralysis to facilitate intubation

• Known or suspected hyperkalemia
• Hypersensitivity
• Family history of malignant hyperthermia
• Myopathies associated with elevated creatine kinase
• Use following the acute phase of injury for major burns, multitrauma, crush injuries, denervation of skeletal muscle, or upper motor neuron injury

Intravenous:

• Onset of paralysis: 30-60 seconds
• Peak: unknown
• Duration: 4-6 minutes (less in pediatrics)

• Cardiovascular: Bradycardia (higher with second dose [not applicable to BCEHS guidelines]; more frequent in children), cardiac arrhythmia, hypertension, hypotension, malignant hyperthermia, tachycardia
• Dermatologic: Skin rash
• Endocrine & metabolic: Hyperkalemia
• Gastrointestinal: Sialorrhea
• Hypersensitivity: Anaphylaxis
• Neuromuscular & skeletal: Fasciculations, jaw tightness, myalgia (postoperative), rhabdomyolysis (with possible myoglobinuric acute renal failure)
• Ophthalmic: Increased intraocular pressure
• Respiratory: Apnea, respiratory depression (prolonged)

Use with caution in children and adolescents.  Acute rhabdomyolysis with hyperkalemia, ventricular arrhythmias and cardiac arrest have been reported (rarely) in pediatrics with undiagnosed skeletal muscle myopathy (e.g., Duchenne muscular dystrophy); occurs soon after administration and requires immediate treatment of hyperkalemia.  Prolonged resuscitation may be required.  Use in pediatrics should be reserved for emergency intubation when immediate airway control is necessary (e.g., laryngospasm, difficult airway, full stomach), or IM use when a suitable vein is inaccessible.

• Anaphylaxis: Severe anaphylactic reactions (some life-threatening and fatal) have been reported; immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during use.  Use caution in patients with previous anaphylactic reactions to other neuromuscular blocking agents.
• Bradycardia: Risk of bradycardia may be increased with second dose (not applicable to BCEHS guidelines) and may occur more in pediatrics.  Occurrence may be reduced by pretreating with anticholinergic agents (e.g., atropine).
• Increased intraocular pressure (IOP): May increase IOP; avoid use in patients in which an increase in IOP is undesirable (e.g., narrow-angle glaucoma, penetrating eye injuries).
• Increased intracranial pressure: May cause a transient increase in intracranial pressure (adequate anesthetic induction prior to administration of succinylcholine will minimize this effect).
• Intragastric pressure: May increase intragastric pressure, which could result in regurgitation and possible aspiration of stomach contents.
• Malignant hyperthermia: Use may be associated with acute onset of malignant hyperthermia; risk may be increased with concomitant administration of volatile anesthetics.
• Neuromuscular cross-sensitivity: Cross-sensitivity with other neuromuscular-blocking agents may occur; use extreme caution in patients with previous anaphylactic reactions to other neuromuscular-blocking agents.
• Vagal tone: May increase vagal tone.