A Comparison of Succinylcholine and Rocuronium for Rapid‐sequence Intubation of Emergency Department Patients

Abstract

Abstract. Objective: To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED). Methods: A oneyear prospective cohort comparison study was performed using a data collection form completed at the time of intubation. Data collected included the reason for the neuromuscular-blocking agent (NMBA) chosen, the time to onset of paralysis, and any complications encountered. Three ten-point numerical descriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall satisfaction with the extent of paralysis. Results: Succinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (Ϯ SD) times of onset of succinylcholine and rocuronium were 39 Ϯ 13 sec and 44 Ϯ 20 sec, respectively (p = 0.04). No patient desaturated and required assisted ventilations while waiting for paralysis to occur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 Ϯ 1.1) than rocuronium (median = 10, mean = 9.1 Ϯ 1.5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 Ϯ 1.6) and rocuronium (median = 9, mean = 9.0 Ϯ 1.6) (p = 0.15). The physician's overall satisfaction with the extent of paralysis was also higher for succinylcholine (median = 10, mean = 9.4 Ϯ 1.3) than rocuronium (median = 10, mean = 8.8 Ϯ 2.0) (p < 0.01). Only one complication, widening of the QRS complex secondary to succinylcholine use in a patient with unsuspected hyperkalemia, could be attributed to the choice of NMBA. Conclusions: Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance. Approximately a fourth of ED RSI patients qualified for use of rocuronium using these high-risk criteria. Key words: rapid-sequence intubation; tracheal intubation; neuromuscular-blocking agents; succinylcholine; rocuronium. ACADEMIC EMERGENCY MEDICINE 2000; 7:1362-1369 R APID-sequence intubation (RSI) is a lifesaving procedure developed to quickly and safely secure the airway of a critically ill or injured patient. In the emergency department (ED), RSI is often chosen over other intubation techniques because the simultaneous onset of deep sedation and paralysis, followed rapidly by tracheal intubation, minimizes the risk of pulmonary aspiration of gastric contents. Rapid-sequence intubation has therefore become the technique of choice for the intubation of patients at risk of having full stomachs, such as ED patients. Indeed, several recent studies have shown RSI as the most common method to achieve airway control in the ED.

Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

“…This absent response to intubation in the majority of critically ill patients is most likely due to the severity of the underlying illness. Based on the present results and previous findings [9,16] we propose that the difference reported for intubation conditions between succinylcholine and rocuronium [3] results entirely from a difference in the response to intubation, an event occurring after the completion of the intubation with marginal relevance for patients' safety. By contrast, succinylcholine and rocuronium do not differ in two aspects of intubation conditions highly relevant for patients' safety - the ease of laryngoscopy and the conditions of the vocal cords.…”

“…In emergency department RSI, Lauren et al . reported that succinylcholine resulted in less body movements as a reaction to intubation than rocuronium, while there was no difference between the two drugs with regard to the degree of vocal cord movements [16]. In emergent RSI in the operating theatre, Sluga et al .…”

Succinylcholine or rocuronium? A meta-analysis of the effects on intubation conditions

“…Recently, the non-depolarising NMB rocuronium (RCR) has emerged as an attractive alternative to SCH for facilitating rapid ETI, as it can also produce paralysis in 01 min (5). When compared with other non-depolarising NMBs, RCR has a rapid and dose-dependent onset of action, while avoiding all of the potential adverse effects listed above as being associated with SCH (6)(7)(8)(9)(10)(11)(12)(13)(14)(15). Accordingly, RCR is particularly useful as a paralytic agent for ETI in patients at risk of hyperkalaemia due to denervation supersensitivity (e.g.…”

“…Several human studies have compared SCH and RCR for use in ETI with respect to a variety of outcome measures, including intubation conditions and adverse effects (6,7,9,11,16). To date, no study comparing the intubation conditions produced by the two NMBs has had a sample size large enough to draw any firm conclusions regarding which agent is more effective.…”

Comparative Study of Succinylcholine with Different Doses of Rocuronium Bromide for Tracheal Intubation during General Anaesthesia

“…[1,2,3] Its rapid onset of effect and ultrashort duration of action permitted rapid endotracheal intubation. [4] But all did not go well for succinylcholine when its adverse effects started surfacing especially fasciculations [5], hyperkalemia [6,7], post-operative muscle pains [8], rise in intragastric, intracranial and intraocular pressure. [9] The aim of research on neuromuscular drugs was to have a nondepolarising muscle relaxant (NDMR), which is like succinylcholine but without its side effects.…”