Should succinylcholine be used for intubation in a patient with a history of cardiac arrest, cardiopulmonary resuscitation (CPR), and return of spontaneous circulation (ROSC)?

Succinylcholine Should Be Avoided in Post-Cardiac Arrest Patients After ROSC

Succinylcholine is relatively contraindicated in patients who have experienced cardiac arrest with CPR and ROSC, and rocuronium (0.9-1.2 mg/kg) should be used instead for rapid sequence intubation. 1, 2, 3

Primary Rationale for Avoiding Succinylcholine

The post-cardiac arrest state creates conditions that significantly increase the risk of succinylcholine-induced hyperkalemia:

• Prolonged critical illness and tissue hypoperfusion during cardiac arrest cause upregulation of nicotinic acetylcholine receptors across muscle membranes, leading to massive potassium efflux when exposed to succinylcholine 2, 4
• The FDA label explicitly contraindicates succinylcholine after the acute phase of injury following multiple trauma or extensive tissue damage, conditions that parallel the cellular injury sustained during cardiac arrest and CPR 3
• Cardiac arrest with CPR causes widespread tissue ischemia, cellular membrane instability, and potential rhabdomyolysis—all risk factors for receptor upregulation that peaks 7-10 days after injury but can begin immediately 2, 4, 3

Critical Safety Concern: Hyperkalemia-Induced Re-Arrest

The most dangerous scenario is administering succinylcholine to a patient who just achieved ROSC:

• If hyperkalemic cardiac arrest occurs after succinylcholine, aggressive treatment requires calcium, insulin/glucose, sodium bicarbonate, and hyperventilation, with successful resuscitation often requiring 10-12 minutes of CPR 2
• Cardiac arrest can occur within minutes of succinylcholine injection, presenting as sudden wide complex tachycardia, bradycardia progressing to asystole, or ventricular fibrillation 4
• Unlike chronic hyperkalemia, succinylcholine-induced hyperkalemia can present with immediate cardiac arrest without warning ECG changes 4

This creates an unacceptable risk: a patient who just survived one cardiac arrest could immediately suffer a second, potentially more difficult to reverse arrest.

Recommended Alternative: Rocuronium

Use rocuronium 0.9-1.2 mg/kg (preferably 1.0-1.2 mg/kg) for rapid sequence intubation in post-cardiac arrest patients: 1, 5

• Rocuronium at 1.2 mg/kg provides similar first-pass intubation success rates compared to succinylcholine (74.6% vs 79.4%), with the 2023 Society of Critical Care Medicine guidelines finding no clinically significant difference 1
• The longer duration of action (30-60 minutes vs 4-6 minutes) is an acceptable trade-off given the dramatically superior safety profile in high-risk patients 1, 5
• Rocuronium has minimal cardiovascular effects, which is particularly important in the hemodynamically unstable post-ROSC period 5

Post-Intubation Management Considerations

After using rocuronium in post-cardiac arrest patients:

• Implement protocolized post-intubation analgosedation immediately to prevent awareness during the prolonged neuromuscular blockade, as rocuronium's longer duration may delay recognition of inadequate sedation 1, 5
• The 2010 AHA guidelines recommend titrated sedation and analgesia for mechanically ventilated post-cardiac arrest patients, with shorter-acting medications preferred 1
• Avoid hyperventilation after ROSC (target PaCO2 40-45 mmHg or ETCO2 35-40 mmHg) as it worsens cerebral ischemia through excessive vasoconstriction 1

Common Pitfall to Avoid

Do not assume that a patient with ROSC and stable vital signs is "safe" for succinylcholine. The cellular injury from cardiac arrest and CPR creates occult risk for receptor upregulation that may not be clinically apparent until catastrophic hyperkalemia occurs after succinylcholine administration 2, 4, 3

Special Circumstance: If Succinylcholine Is Inadvertently Given

If succinylcholine has already been administered and cardiac arrest occurs:

• Immediately suspect hyperkalemia and begin aggressive treatment with calcium gluconate 10% (15-30 mL IV over 2-5 minutes) or calcium chloride 10% (5-10 mL IV over 2-5 minutes) to stabilize cardiac membranes 2
• Administer insulin 10 units regular IV plus 25g dextrose (50 mL D50) over 15-30 minutes for intracellular potassium shifting 2
• Continue CPR for at least 10-12 minutes while administering adjuvant therapies, as successful resuscitation from succinylcholine-induced hyperkalemia requires prolonged efforts 2
• Monitor continuously for at least 2-4 hours after stabilization due to risk of rebound hyperkalemia, checking serum potassium every 2-4 hours 2, 4