In this episode, I’ll discuss the use of succinylcholine vs rocuronium for tracheal intubation in emergency department patients.
Few topics are as hotly debated in emergency medicine circles as the use of succinylcholine vs rocuronium for tracheal intubation.
In brief, the “pro succinylcholine” group emphasizes its rapid onset and short duration of action, while the “pro rocuronium” group values its lack of both contraindications and serious but rare side effects like hyperkalemia or malignant hyperthermia.
A group of authors recently published in Annals of Emergency Medicine a secondary analysis of randomized trials looking at patient outcomes associated with the use of succinylcholine or rocuronium for emergency tracheal intubation.
Data from nearly 2400 critically ill adult patients undergoing tracheal intubation in an ED or ICU were analyzed. About 4 times as many patients received rocuronium as did succinylcholine. The analysis focused on the incidence of successful intubation on the first attempt and severe complications during tracheal intubation.
The succinylcholine group achieved first attempt success 78.9% of the time compared to 81% for rocuronium. While this had an adjusted odds ratio of 0.87 in favor of rocuronium, the 95% confidence interval was 0.65 to 1.15, making the difference not statistically significant.
The succinylcholine group experienced a severe complication 14.1% of the time compared to 24.5% for rocuronium. While this had an adjusted odds ratio of 0.88 in favor of succinylcholine, the 95% confidence interval was 0.62 to 1.26, making the difference not statistically significant.
The incidences of cardiac arrest after intubation and death were both higher in the rocuronium group, but after adjusting for covariates there was no statistical difference between groups.
The authors concluded:
Our study combined with prior literature highlights that, for critically ill adults undergoing tracheal intubation in current clinical care, succinylcholine and rocuronium are commonly used medications, each agent has potential risks and benefits, and no strong data are available to inform the choice between the 2 agents for intubation in the ED or ICU.
While there are plenty of reasons to support using one paralytic over the other, when it comes down to an actual difference in outcomes, the reasons for or against a particular paralytic are largely trivial. However, in an individual provider’s mind, the differences can be significant. For example, imagine you are a physician who prefers succinylcholine’s short duration of action in a difficult airway scenario because you fear rocuronium’s long duration might lead to a can’t intubate, can’t ventilate scenario if the first attempt is not successful. If your pharmacist recommends rocuronium, you will likely have a strong feeling of discomfort and nervousness using it even if you agree to the intervention. And that’s the last thing I want on my physician’s mind if they are trying to focus on intubating a patient with a difficult airway. For that reason, I’ve concluded that the best paralytic to use for tracheal intubation is usually going to be whatever one the provider prefers.
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