A study just published this month in Annals of Emergency Medicine compared the 2 most common paralytics we use in the ED for RSI, rocuronium and succinylcholine. The primary outcome studied was first pass success rate, and the secondary outcome was adverse effects including cardiac arrest, hypotension, dental trauma, and dysrhythmias. While succinylcholine used to be the more commonly used agent, use of rocuronium is rising. Obviously a lot of this is institution specific. The difference in paralysis onset and offset may affect your success rate and the patient’s outcome, as well as being aware of contraindications for each. Anesthesia literature has suggested succinylcholine is better for RSI, and the most recent Cochrane review in 2015 had found succinylcholine had led to superior intubating conditions (used the Goldberg scale that scores based on ease of intubation, vocal cord movement, and patient response like coughing or bucking). For what it’s worth, this Cochrane review also found that thiopental was the superior induction agent, which doesn’t change anything for most places in North America where it’s not readily available.

The Annals study analyzed 4275 intubations from the National Emergency Airway Registry (NEAR) and found no difference between rocuronium and succinylcholine in first pass success (87.5% and 87%) nor in adverse effects (14.8% vs 14.7%). There was also no significant difference in glottic view. Why is this study different from the Cochrane review? The review had used a lot of RCTs from the OR setting as opposed to this study which looked prospectively at ED cases only. The next step would be a clinical interventional trial in the ED setting only. Anyone interested?


Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study
April, Michael D. et al. Annals of Emergency Medicine. December 2018. Volume 72, Issue 6 , 645 – 653.

Tran  DTT, Newton  EK, Mount  VAH, Lee  JS, Wells  GA, Perry  JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD002788. DOI: 10.1002/14651858.CD002788.pub3.