Letters Section Editor: Stephen J. Lurie,
MD, PhD, Senior Editor.
To the Editor: Dr Lee1 noted
that "early endotracheal intubation and ventilatory support are critical .
. . " in treating severely injured patients after sarin exposure. We disagree,
however, with his assertion that succinylcholine should be avoided during
rapid sequence intubation in these patients.
Death from sarin exposure is generally because of hypoxia from airway
obstruction, weakness of the respiratory muscles, seizures, or respiratory
failure.2 In patients with severe trauma,
rapid sequence intubation with succinylcholine is the standard method of airway
management. As Lee stated, sarin inhibits both acetylcholinesterase ("true"
cholinesterase) and butyrylcholinesterase (pseudocholinesterase). Because
succinylcholine is metabolized by butyrylcholinesterase, a patient exposed
to sarin who receives succinylcholine would be expected to have prolonged
neuromuscular blockade. This has been reported in patients who received succinylcholine
after organophosphate insecticide poisoning.3 The
duration of paralysis in most cases, however, was less than 4 hours. Similar
prolongation of neuromuscular blockade has been reported for mivacurium, a
nondepolarizing neuromuscular blocker (NMB) that is also metabolized by butyrylcholinesterase.4- 6
DeBalli P, Cook DR. Treatment of Sarin Exposure. JAMA. 2004;291(2):181. doi:10.1001/jama.291.2.181-b