Is it safe to use succinylcholine in a 15-year-old patient?

Succinylcholine Use in a 15-Year-Old

Succinylcholine can be used in a 15-year-old, but should be reserved for emergency intubation or situations requiring immediate airway control, as this age group should receive adult dosing (1.0 mg/kg) and faces the same serious risks as younger pediatric patients, including potentially fatal hyperkalemia from undiagnosed myopathies. 1, 2

Age-Appropriate Dosing

• A 15-year-old should receive adult dosing of 1.0 mg/kg for intubation, as patients >10 years are dosed as adults 1
• This represents a transition point where pediatric-specific considerations still apply regarding safety monitoring, but dosing follows adult protocols 1

Critical Safety Considerations for Adolescents

Risk of Undiagnosed Myopathy

• Adolescents remain at risk for sudden cardiac arrest from acute rhabdomyolysis with hyperkalemia if they have occult skeletal muscle myopathies like Duchenne muscular dystrophy 2
• While most cases occur in males <8 years old, there have been documented reports in adolescents, making this a relevant concern for a 15-year-old 2
• The syndrome presents as sudden cardiac arrest within minutes after succinylcholine administration, with peaked T-waves as an early ECG sign 2

Cardiovascular Effects

• Bradycardia risk persists in adolescents, particularly with repeat dosing 2
• Atropine should be available to prevent bradyarrhythmias, though the incidence is lower than in younger children 1, 2

Malignant Hyperthermia

• Succinylcholine remains a known trigger for malignant hyperthermia at all ages 1
• Dantrolene must be immediately available wherever succinylcholine is used 1

Recommended Clinical Approach

When to Use Succinylcholine

• Reserve for emergency intubation or instances requiring immediate airway securing (laryngospasm, difficult airway, full stomach) 2
• The rapid onset (58-95 seconds to maximum block) and short duration (4-6 minutes) make it valuable for true emergencies 1, 3

When to Choose Rocuronium Instead

• Use rocuronium 0.9-1.2 mg/kg as the alternative when succinylcholine is contraindicated or for non-emergent intubations 1, 4
• Rocuronium provides comparable intubation conditions with onset within 60 seconds, though duration is longer (30-60 minutes) 1, 5
• Sugammadex should be rapidly available when rocuronium is used to allow reversal if needed 4

Absolute Contraindications

• History of malignant hyperthermia 1
• Known or suspected myopathies (Duchenne muscular dystrophy, other muscle disorders) 1, 2
• Patients immobilized >3 days 1
• Burns, crush injuries, spinal cord injuries, or neuromuscular diseases where hyperkalemia risk is elevated 1

Practical Monitoring Requirements

• Continuous ECG monitoring to detect peaked T-waves as an early sign of hyperkalemia 2
• Personnel skilled in airway management must be present 1
• Immediate availability of resuscitative medications: intravenous calcium, bicarbonate, glucose with insulin 2
• Be prepared for extraordinary and prolonged resuscitation efforts if cardiac arrest occurs, as routine measures are often unsuccessful 2

Key Clinical Pitfall

• A careful history and physical examination may not identify all at-risk patients, as developmental delays suggestive of myopathy may be subtle 2
• Preoperative creatine kinase can identify some but not all patients at risk 2
• The difficulty in identifying at-risk patients is precisely why succinylcholine should be reserved for emergencies in all pediatric and adolescent patients 2