The Journal
of Emergency
Medune,
Vol 10, pp 759-766,
0 Regarding the Uncooperative
Prlnted in the USA
1992
Trauma Patient
0 1992 Pergamon
Press Ltd
the authors’ paper is devoid of any reference to methods for insuring that the paralyzed patient is amnestic for the event. The terror experienced by patients who are unable to move or breathe, but are acutely aware of their plight, has been well-documented (5). Neuromuscular blockade results in a patient who appears blissfully asleep (noncombative), yet who may be fully aware, in pain, and may recall the entire experience. Neuromuscular blocking agents (NMBs) do not provide amnesia, sedation, anesthesia, or analgesia. Second, the authors do not mention if and how neuromuscular blockade is reversed prior to extubation of those patients paralyzed with long-acting NMBs. Third, we would urge those who encourage the use of NMBs to accurately describe their pharmacology. Kuchinski et al state that using a nondepolarizing NMB may permit omission of a defasciculating agent. Because nondepolarizers do not result in neuromuscular membrane depolarization (fasciculation), a defasciculator is never required. Similarly, the authors suggest that malignant hyperthermia (MH) is associated with succinylcholine-induced fasciculation. While succinylcholine is a known triggering agent for MH, fasciculation per se is probably not the mechanism.
Kuchinski et al recently described their experience with pharmacologic paralysis of the uncooperative trauma patient (1). This technique was employed to control their patients’ agitation and combativeness, ostensibly to facilitate rapid diagnostic workup and therapeutic intervention. None of the 19 patients in the low injury severity subgroup (LSI) died as a result of trauma, yet one (5%) died from CNS anoxia secondary to esophageal intubation. We wish to take issue with the tone of the authors’ conclusion, and to strongly support Dr. Walls’ editorial statement condemning the use of neuromuscular blockade solely for the purpose of controlling disruptive behavior (2).
Kuchinski et al conclude that paralysis and intubation of patients with LSI may be difficult to defend because such patients are more likely intoxicated, less likely to be hospitalized, and require more costly care. We feel their emphasis fails to highlight the fact that one LSI patient died as a direct result of an unwarranted intervention. We have no quarrel with paralysis of the trauma patient who would otherwise require intubation for definitive airway control or hyperventilation. We submit, however, that neuromuscular blockade solely to control an uncooperative patient is at best inhumane, and at worst a potentially lethal intervention. The authors’ 5% incidence of failure to intubate is consistent with a previously reported 4% failure to intubate paralyzed emergency department patients (3). Inadequate ventilation, esophageal intubation, and difficult tracheal intubation accounted for three-fourths of adverse respiratory events in anesthesia. Death or brain damage resulted from 85% of these cases (4). Is there any supportive evidence that controlling the trauma victim’s unseemly behavior with paralysis has ever improved diagnostic yield in such a way as to positively affect morbidity or mortality? Kuchinski et al have certainly provided us with evidence that such a technique may result in mortality. Three other points deserve brief comment. First, =
CopyrIght
Joseph M. Neal, MD Julia E. Pollock, MD Seattle, Washington
REFERENCES 1. Kuchinski J, Tinkoff G, Rhodes M, Becher JW Jr. Emergency intubation for paralysis of the uncooperative trauma patient. J Emerg Med. 1991;9:9-12. 2. Walls RM. The combative trauma patient: a paradigm of trauma leadership. J Emerg Med. 1991;9:67-8. 3. Roberts DJ, Clinton JE, Ruiz E. Neuromuscular blockade for critical patients in the emergency department. Ann Emerg Med. 1986;15:152-6. 4. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990;72:828-33. 5. Loper KA, Butler S, Nessly M, Wild L. Terror in the ICU: paralyzed with pain. Anesth Analg. 1989;68:S170.
for Letters-Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted.
Guidelines
0736-4679/92 $5.00 + .OO 759
of Emergency
Medune,
Vol 10, pp 759-766,
0 Regarding the Uncooperative
Prlnted in the USA
1992
Trauma Patient
0 1992 Pergamon
Press Ltd
the authors’ paper is devoid of any reference to methods for insuring that the paralyzed patient is amnestic for the event. The terror experienced by patients who are unable to move or breathe, but are acutely aware of their plight, has been well-documented (5). Neuromuscular blockade results in a patient who appears blissfully asleep (noncombative), yet who may be fully aware, in pain, and may recall the entire experience. Neuromuscular blocking agents (NMBs) do not provide amnesia, sedation, anesthesia, or analgesia. Second, the authors do not mention if and how neuromuscular blockade is reversed prior to extubation of those patients paralyzed with long-acting NMBs. Third, we would urge those who encourage the use of NMBs to accurately describe their pharmacology. Kuchinski et al state that using a nondepolarizing NMB may permit omission of a defasciculating agent. Because nondepolarizers do not result in neuromuscular membrane depolarization (fasciculation), a defasciculator is never required. Similarly, the authors suggest that malignant hyperthermia (MH) is associated with succinylcholine-induced fasciculation. While succinylcholine is a known triggering agent for MH, fasciculation per se is probably not the mechanism.
Kuchinski et al recently described their experience with pharmacologic paralysis of the uncooperative trauma patient (1). This technique was employed to control their patients’ agitation and combativeness, ostensibly to facilitate rapid diagnostic workup and therapeutic intervention. None of the 19 patients in the low injury severity subgroup (LSI) died as a result of trauma, yet one (5%) died from CNS anoxia secondary to esophageal intubation. We wish to take issue with the tone of the authors’ conclusion, and to strongly support Dr. Walls’ editorial statement condemning the use of neuromuscular blockade solely for the purpose of controlling disruptive behavior (2).
Kuchinski et al conclude that paralysis and intubation of patients with LSI may be difficult to defend because such patients are more likely intoxicated, less likely to be hospitalized, and require more costly care. We feel their emphasis fails to highlight the fact that one LSI patient died as a direct result of an unwarranted intervention. We have no quarrel with paralysis of the trauma patient who would otherwise require intubation for definitive airway control or hyperventilation. We submit, however, that neuromuscular blockade solely to control an uncooperative patient is at best inhumane, and at worst a potentially lethal intervention. The authors’ 5% incidence of failure to intubate is consistent with a previously reported 4% failure to intubate paralyzed emergency department patients (3). Inadequate ventilation, esophageal intubation, and difficult tracheal intubation accounted for three-fourths of adverse respiratory events in anesthesia. Death or brain damage resulted from 85% of these cases (4). Is there any supportive evidence that controlling the trauma victim’s unseemly behavior with paralysis has ever improved diagnostic yield in such a way as to positively affect morbidity or mortality? Kuchinski et al have certainly provided us with evidence that such a technique may result in mortality. Three other points deserve brief comment. First, =
CopyrIght
Joseph M. Neal, MD Julia E. Pollock, MD Seattle, Washington
REFERENCES 1. Kuchinski J, Tinkoff G, Rhodes M, Becher JW Jr. Emergency intubation for paralysis of the uncooperative trauma patient. J Emerg Med. 1991;9:9-12. 2. Walls RM. The combative trauma patient: a paradigm of trauma leadership. J Emerg Med. 1991;9:67-8. 3. Roberts DJ, Clinton JE, Ruiz E. Neuromuscular blockade for critical patients in the emergency department. Ann Emerg Med. 1986;15:152-6. 4. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990;72:828-33. 5. Loper KA, Butler S, Nessly M, Wild L. Terror in the ICU: paralyzed with pain. Anesth Analg. 1989;68:S170.
for Letters-Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted.
Guidelines
0736-4679/92 $5.00 + .OO 759
