Page 45 - Journal of Special Operations Medicine - Summer 2014

Comparison of Muscle Paralysis
After Intravenous and Intraosseous Administration

of Succinylcholine in Swine

Michael J. Loughren, CRNA, PhD; James Kilbourn, BSN; Kevin Worth, CRNA, MS;
James Burgert, CRNA, DNAP; Brian Gegel, CRNA, DNAP; Don Johnson, PhD

ABSTRACT
Aim: To compare the onset and duration of intravenous appropriately referred to as rapid sequence induction
(IV) and intraosseous (IO) administration of succinyl- and intubation (RSII). The technique, which has been in
choline in swine. Methods: Electromyographic (EMG) use since the 1970s, is used to quickly intubate patients
amplitudes were used to characterize muscle paralysis who are at an increased risk of aspiration. The goal is
following administration of succinylcholine via the IV to minimize the time interval between loss of protective
or IO route in four Yorkshire-cross swine. Results: The airway reflexes and tracheal intubation. It is largely con-
onset of action of succinylcholine was statistically lon- sidered the standard of care for anesthesia induction in
ger after IO administration (0.97 ± 0.40) compared with patients with a full stomach.
IV administration (0.55 ± 0.26) (p = .048). Duration of
action was unaffected by route of administration: IO, The technique has many variations but generally in-
11.4 ± 4.2, and IV, 12.9 ± 3.8 (p = .65). Conclusions: cludes preoxygenation; rapid injection of an induction
Succinylcholine can be effectively administered via the agent such as propofol or etomidate, immediately fol-
IO route. However, an increased dose may be necessary lowed by succinylcholine or rocuronium; and avoidance
when administering succinylcholine via the IO route to of ventilation before placement of a cuffed endotracheal
achieve the same rapid onset as standard IV dosing. tube. Muscle paralysis of the oropharynx, larynx, and
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diaphragm greatly improves intubating conditions and
Keywords: intraosseous, succinylcholine, rapid sequence success rate. In addition, it decreases complications such
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induction as airway trauma, aspiration, and death. Intravenous
succinylcholine provides favorable intubating condi-
tions in less than 1 minute, and even a small delay would
be undesirable. Information on the onset, duration, and
Background
optimal dose of IO succinylcholine would be of great
Rapid vascular access is required for resuscitation, ad- benefit to emergency medical providers. The purpose of
ministration of life-saving medications, and facilita- this study was to quantify and compare the onset and
tion of airway management following traumatic injury. duration of action of IV and IO administration of suc-
However, peripheral IV access may be complicated by cinylcholine in a swine model.
shock and subsequent vascular collapse. Injury patterns
to extremities make many conventional vascular access
sites unusable. In these situations, the IO route has been Methods
1
successfully used during military operations over the The study was a prospective, crossover, experimental
past decade. Despite its increased use in civilian and design. The subjects were equally divided with respect
2,3
military emergency medical management and many case to order of administration. The protocol was approved
reports of a wide variety of medications being adminis- by the local institutional animal care and use committee.
tered via the IO route, there are very little data sup- The animals received care in compliance with the Ani-
4,5
porting its bioequivalence to the IV route. These data mal Welfare Act and the “Guide for the Use of Labora-
are necessary because dose adjustments may be required tory Animals.”
to achieve the same clinical effect when administering
medications by the IO route as one would expect when General anesthesia was induced in four Yorkshire-cross
administering the same medication by the IV route. swine weighing between 70 and 75 kg with an intramus-
cular injection of tiletamine and zolazepam (4–8mg/kg).
One such medication, succinylcholine, is commonly used The animals were orally intubated and maintained with
in a rapid sequence induction (RSI), sometimes more isoflurane (2%). Physiological variables were monitored

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