NMB for intubation in organophosphate poisoning

Q: Which of the following neuromuscular blockade (NMB) should NOT be used for intubation in patients with suspected organophosphate (OP) poisoning? (select one)

A) Succinylcholine 

B) Rocuronium

Answer: A

Patients with suspected organophosphate (OP) poisoning should never be intubated with succinylcholine, because it is metabolized by acetylcholinesterase, which is inhibited by OP. This leads to exaggerated and prolonged neuromuscular blockade in these patients. 

Rocuronium which is a non-depolarizing NMB agent is preferred but may require a higher dose as standard doses may be less effective, due to competitive inhibition at the neuromuscular junction. 

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References:

1. Sungur M, Güven M. Intensive care management of organophosphate insecticide poisoning. Crit Care. 2001 Aug;5(4):211-5. doi: 10.1186/cc1025. Epub 2001 May 31. PMID: 11511334; PMCID: PMC37406.

2. Eddleston M, Mohamed F, Davies JO, Eyer P, Worek F, Sheriff MH, Buckley NA. Respiratory failure in acute organophosphorus pesticide self-poisoning. QJM. 2006 Aug;99(8):513-22. doi: 10.1093/qjmed/hcl065. Epub 2006 Jul 22. PMID: 16861715; PMCID: PMC1525210.

3. Dhanarisi J, Shihana F, Harju K, Mohamed F, Verma V, Shahmy S, Vanninen P, Kostiainen O, Gawarammana I, Eddleston M. A pilot clinical study of the neuromuscular blocker rocuronium to reduce the duration of ventilation after organophosphorus insecticide poisoning. Clin Toxicol (Phila). 2020 Apr;58(4):254-261. doi: 10.1080/15563650.2019.1643467. Epub 2019 Jul 31. PMID: 31364415.