Patient with acute respiratory distress
You are an intensive care physician on duty in the surgical ICU who is called to a patient with acute respiratory distress, paraplegia, and a history of stroke. The patient is significantly agitated, hypoxic, and experiencing deterioration of consciousness. Urgent intubation with rapid induction of anesthesia is indicated. For rapid muscle relaxation, succinylcholine is administered in the usual dose together with a sedative. Intubation proceeds without complications, and ventilation is initiated. However, approximately one minute after the administration of succinylcholine, the patient's condition suddenly deteriorates – bradycardia, widening of the QRS complexes, and significantly peaked T waves appear on the monitor. Blood pressure drops. You suspect severe hyperkalemia. What will be your next step?
Examination
History
S: Acute dyspnea, agitation, decreased level of consciousness.
A: No known allergies.
M: Chronic medication according to documentation (neurological drugs, antihypertensives)
P: Previous stroke with subsequent paraplegia 6 m ago, long-term immobilization.
L: Progressive dyspnea over the last hours, continuous feedings through a PEG
E: Admitted to ICU for respiratory insufficiency.
Acute assessment
A – Patient after RSI, endotracheal tube size 8,5, fixed on 22cm
B – SpO₂ before intubation 75%, brief improvement after initiation of ventilation, now again a tendency to decline. Bilateral ventilation, no clear signs of pneumothorax.
C – Bradycardia, wide QRS complexes, peaked T waves. Hypotension. Palpable central pulse, weak peripheral pulse. Central venous catheter inserted.
D – GCS 3. Pupils isocoric, after muscle relaxans
E – Signs of chronic immobilization. treated first-degree pressure ulcer in sacral area
