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CHAPTER 27 Skeletal Muscle Relaxants 491

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C ASE STUD Y ANSWER

Because of trauma and associated pain, it is assumed that dose, rocuronium has a very rapid onset, which approaches
gastric emptying will be significantly delayed. To avoid pos- but does not quite equal that of succinylcholine.
sible aspiration at the time of intubation, a very rapid-acting In the case vignette, you are unable to intubate the patient
muscle relaxant should be used so the airway can be secured and may be unable to mask ventilate the patient. In this
with an endotracheal tube. Usually, succinylcholine would setting, use of the reversal agent sugammadex is indicated.
be the agent of choice in this case; however, the patient has Since a large dose of rocuronium was just given, a dose of
a ruptured (open) globe. Succinylcholine is contraindicated 16 mg/kg of sugammadex needs to be given to rapidly and
in patients with an open globe because it raises intraocular completely reverse the effects of the neuromuscular block-
pressure and could possibly result in extrusion of aqueous ing agent and allow return of spontaneous ventilation. In
or vitreous humor. Therefore, a rapid sequence intubation order to proceed with surgery, another technique (such as
should be performed with high-dose (up to 1.2 mg/kg) an awake fiberoptic-assisted intubation) should be used to
rocuronium, a nondepolarizing muscle relaxant. At this secure the airway.