Editing Rapid sequence induction (section)

==== Paralytics ====
Paralytics are also known as [[neuromuscular-blocking drugs]] (NMB). NMB can reduce the complication rates of rapid sequence induction such as inadequate oxygenation of the blood, airway complications, and instability of the cardiovascular system. NMB can be divided into two types: depolarising and non-depolarizing blockers.<ref name=":9">{{Citation |last1=Cook |first1=Danielle |title=Neuromuscular Blockade |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK538301/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30855885 |access-date=2022-11-10 |last2=Simons |first2=David J.}}</ref> Depolarizing blockers resembles the [[acetylcholine]] and activates the motor end-plate of the [[neuromuscular junction]] (NMJ). Meanwhile, non-depolarizing blockers competitively blocks the NMJ without activating the motor end plate.<ref name="Joanna 2014" />

===== Depolarizing blockers =====
* [[Suxamethonium|Succinylcholine]] – This drug has rapid onset of action and fast duration. Its dosages are between 1 and 2&nbsp;mg/kg body weight with common dosage of 100&nbsp;mg. The drug can only be kept under room temperature for 14 days. Therefore, for longer shelf life, it has to be kept under temperatures from {{convert|3.3|C|F}} to {{convert|8.7|C|F}}.  When the intravenous access is not obtainable, the 3 to 4&nbsp;mg/kg of intramuscular doses can be given (usual dose of 300&nbsp;mg). However, duration of onset will be delayed to 3 to 4 minutes. Repetitive dosages of succinylcholine are discouraged to prevent vagal stimulation which leads to bradycardia.<ref name="Joanna 2014"/> There are many absolute contraindications to succinylcholine including recent [[stroke]], [[hyperkalemia]], [[burn]] patients, immobilized patients (i.e. wheelchair bound).<ref>{{Citation |last1=Cook |first1=Danielle |title=Neuromuscular Blockade |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK538301/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30855885 |access-date=2022-11-10 |last2=Simons |first2=David J.}}</ref> This is due to the upregulation of [[Neuromuscular junction|neuromuscular junctions]].<ref name=":9" /> Additionally, cautions should be used in patients with reduced serum [[Butyrylcholinesterase|plasma cholinesterase]], as this is how the drug removed from the body.<ref name=":10">{{Citation |last1=Hager |first1=Heather H. |title=Succinylcholine Chloride |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK499984/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29763160 |access-date=2022-11-10 |last2=Burns |first2=Bracken}}</ref> In patients with decreased [[Butyrylcholinesterase|plasma cholinesterase]], the paralysis from succinylcholine can increase significantly in duration.<ref name=":10" /> A common side effect of succinylcholine includes [[Myalgia|myalgias]] after neuromuscular induced [[Fasciculation|fasciculations]] upon induction.<ref name=":10" />

===== Non-depolarizing blockers =====
* [[Rocuronium]] – The dosage of rocuronium is between 0.6 and 1.2&nbsp;mg/kg. Since rocuronium has longer duration of onset, caution should be taken for those who are difficult to bag-mask ventilate.<ref name="Joanna 2014"/> While rare, [[Anaphylaxis|anaphylactic]] reactions have been known to occur with rocuronium.<ref>{{Cite journal |last1=Reddy |first1=Jeffrey I. |last2=Cooke |first2=Peter J. |last3=van Schalkwyk |first3=Johan M. |last4=Hannam |first4=Jacqueline A. |last5=Fitzharris |first5=Penny |last6=Mitchell |first6=Simon J. |date=2015-01-01 |title=Anaphylaxis Is More Common with Rocuronium and Succinylcholine than with Atracurium |journal=Anesthesiology |volume=122 |issue=1 |pages=39–45 |doi=10.1097/aln.0000000000000512 |pmid=25405395 |s2cid=9596238 |issn=0003-3022|doi-access=free }}</ref> While historically this was not the paralytic of choice in RSI due to the longer duration of action, with the recent approval of [[Sugammadex]] as a reversal agent the concern for a long duration of paralysis is reduced.<ref>{{Citation |last1=Jain |first1=Ankit |title=Rocuronium |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK539888/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30969710 |access-date=2022-11-10 |last2=Wermuth |first2=Harrison R. |last3=Dua |first3=Anterpreet |last4=Singh |first4=Karampal |last5=Maani |first5=Christopher V.}}</ref>
* [[Vecuronium bromide|Vecuronium]] – The dosage of this drug is between 0.08 and 0.1&nbsp;mg/kg. Vecuronium is only used when there is a shortage of drugs such as succinylcholine and rocuronium.<ref name="Joanna 2014"/>

===== Reversal agents =====
* [[Sugammadex]] – It is used as a reversal agent for [[rocuronium]] and [[Vecuronium bromide|vecuronium]]. It works by encapsulating the paralytic drug thus preventing it from acting on the binding sites.<ref name=":11">{{Cite journal |last1=Schaller |first1=Stefan Josef |last2=Fink |first2=Heidrun |date=2013 |title=Sugammadex as a reversal agent for neuromuscular block: an evidence-based review |journal=Core Evidence |volume=8 |pages=57–67 |doi=10.2147/CE.S35675 |issn=1555-1741 |pmc=3789633 |pmid=24098155 |doi-access=free }}</ref> The dose of 16&nbsp;mg/kg is used for immediate reversal after administration such as during RSI.<ref name=":11" /> Doses of 2&nbsp;mg/kg and 4&nbsp;mg/kg are used if the patient has twitches evident on a [[Neuromuscular monitoring|twitch monitor]] and terminates the rocuronium action within 3 minutes.<ref>{{Cite journal |last1=Otomo |first1=Shigeaki |last2=Iwasaki |first2=Hajime |last3=Takahoko |first3=Kenichi |last4=Onodera |first4=Yoshiko |last5=Sasakawa |first5=Tomoki |last6=Kunisawa |first6=Takayuki |last7=Iwasaki |first7=Hiroshi |date=2014 |title=Prediction of Optimal Reversal Dose of Sugammadex after Rocuronium Administration in Adult Surgical Patients |journal=Anesthesiology Research and Practice |volume=2014 |pages=848051 |doi=10.1155/2014/848051 |issn=1687-6962 |pmc=3942288 |pmid=24672542|doi-access=free }}</ref> The FDA initially did not approve Sugammadex due to concerns over potential allergic reactions, however it was subsequently approved on December 15, 2015, for use in the United States.<ref>{{Cite journal |last1=Cada |first1=Dennis J. |last2=Levien |first2=Terri L. |last3=Baker |first3=Danial E. |date=July 2016 |title=Sugammadex |journal=Hospital Pharmacy |volume=51 |issue=7 |pages=585–596 |doi=10.1310/hpj5107-585 |issn=0018-5787 |pmc=4981107 |pmid=27559192}}</ref>
* [[Neostigmine]] – It can be used to reverse nondepolarizing neuromuscular blocking agents which cannot be reversed with Sugammadex, although its onset is much slower. It works by competitively inhibiting [[acetylcholinesterase]], an enzyme that breaks down acetylcholine.<ref name=":12">{{Cite journal |last1=Neely |first1=Grant A. |last2=Sabir |first2=Sarah |last3=Kohli |first3=Arpan |date=2022-08-15 |title=Neostigmine |publisher=StatPearls |pmid=29261883 |url=https://www.ncbi.nlm.nih.gov/books/NBK470596/#:~:text=Neostigmine%20is%20water-soluble,%20an,neuromuscular%20blocking%20agents%20after%20surgery. |language=en}}</ref> This results in an accumulation of acetylcholine present in the neuromuscular junction, effectively reversing the paralysis of the patient.<ref name=":12" /> The dosage is between 0.03 and 0.07&nbsp;mg/kg. A common side effect of this drug is [[bradycardia]].<ref name=":12" /> Therefore, [[glycopyrrolate]], an [[anticholinergic]] drug, should be given immediately prior to neostigmine to prevent bradycardia.<ref name="Joanna 2014"/>