Rapid-sequence intubation of head trauma patients: Prevention of fasciculations with pancuronium versus minidose succinylcholine

Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury

“…The overall intubation success rate for OTI with drugassistance was 96.3% (5,745 of 5,963) ( 14,18,34,40,49,64,68,80,111,115,233,234,236,241 The GCS score, when available, was between 6 and 12 in most patients. 26,34,37,38,[48][49][50] This literature indicates that there is a substantial experience with emergency drug-assisted OTI in trauma patients in multiple settings and that the intubation success rate ap-…”

“…203 Fourteen investigators indicate that a drug regimen used to enhance OTI success should include the need to prevent hemodynamic instability. 14,19,24,32,38,40,49,81,144,229 -231,235,236 Multiple authors indicate that a drug regimen used to enhance OTI success should include the need to prevent vomiting 14,19,24,26,32,37,38,40,80,229,230,233,236 and the extrusion of intraocular contents. 18,24,37,40,81,233 Nine investigators have described OTI in 285 patients with cervical spine injury without neurologic deterioration.…”

“…14,19,24,32,38,40,49,81,144,229 -231,235,236 Multiple authors indicate that a drug regimen used to enhance OTI success should include the need to prevent vomiting 14,19,24,26,32,37,38,40,80,229,230,233,236 and the extrusion of intraocular contents. 18,24,37,40,81,233 Nine investigators have described OTI in 285 patients with cervical spine injury without neurologic deterioration. 14,18,21,39,63,88,89,234,239 This literature indicates that OTI is relatively safe for patients with cervical spine injury.…”

Intubation of the Neurologically Injured Patient

“…A small, randomized trial of patients undergoing RSI in the ED for head injury with defasciculating doses of succinylcholine or pancuronium followed by full-dose succinylcholine found that the two groups had equal amounts of fasciculation during intubation (70).…”

Assessment and Management of the Pediatric Airway

“…Succinylcholine provides safe and effective neuromuscular blockade for the majority of patients, although rocuronium or high-dose vecuronium (0.25-0.3 mg/kg) is an acceptable alternative if there are contraindications or concerns regarding the use of succinylcholine. Pretreatment with a defasciculating dose of an NDNMB may prevent the muscle fasciculations (and the subsequent pain and soreness that result) associated with succinylcholine, although the available evidence is limited [85,162,[197][198][199][200]. Typically, one-tenth of the normal dose of an NDNMB is administered 1-3 min before administering succinylcholine (e.g., vecuronium, one-tenth of 0.1 mg/kg/dose = 0.01 mg/kg defasciculating dose).…”