A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients

Objective: To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED). Methods: A one-year 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 (± SD) times of onset of succinylcholine and rocuronium were 39 ± 13 sec and 44 ± 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 ± 1.1) than rocuronium (median = 10, mean = 9.1 ± 1.5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 ± 1.6) and rocuronium (median = 9, mean = 9.0 ± 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 ± 1.3) than rocuronium (median = 10, mean = 8.8 ± 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.