EBQ:Comparison of Succinylcholine and Rocuronium for RSI

Complete Journal Club Article
Laurin EG, et al. "A Comparison of Succinylcholine and Rocuronium for Rapid-sequence Intubation of Emergency Department Patients". Academic Emergency Medicine. 2000. 7(12):1362-9.
PubMed PDF

Clinical Question

How do succinylcholine and rocuronium compare for use in rapid-sequence intubation in the emergency department?


Both succinylcholine and rocuronium produce fast and reliable paralysis for RSI in the ED.

Major Points

Outcome Succinylcholine Rocuronium p value
Measured time of onset (± SD) 39 ± 13 seconds 44 ± 20 seconds 0.04
Frequency of body movements 0-10 (± SD) 9.5 ± 1.1 9.1 ± 1.5 0.01
Vocal cord movements 0-10 (± SD) 9.2 ± 1.6 9.0 ± 1.6 0.15
Physician satisfaction 0-10 (± SD) 9.4 ± 1.3 8.8 ± 2.0 <0.01
Related complications QRS widening in 1 pt with hyperkalemia 0 related complications --
Unrelated complications 7 complications in 7 patients 7 complications in 6 patients --
Mean dosage used 1.7 mg/kg 1.0 mg/kg --


  • Succinylcholine given to 5 patients with pre-existing but unknown hyperkalemia
    • 4 pts with serum K between 5.1-6.0 mmol/L
    • 1 pt with serum K for 7.1 mmol/L.
      • Found obtunded with scalp contusions, without known medical history. Developed widened QRS 30 seconds after succinylcholine administration. Pt found to be in DKA, given medical management for hyperkalemia, and had no clinical adverse affects.
  • No paralytic-related complications were noted in the rocuronium group
  • No patient desaturated and required assisted ventilations while waiting for paralysis to occur
  • Both groups had complications unrelated to paralytic used
    • These included vomiting, sinus bradycardia during difficult intubation, tube obstruction, chipped teeth, minor oropharyngeal lacerations

Study Design

  • Prospective cohort study at the UC Davis Medical Center, a level 1 trauma center
  • Emergency physicians attended a class about rocuronium before study, where they were given information on its pharmacologic properties, indications for use, and dose for intubation (1.0 mg/kg used)
  • Agreed indications for rocuronium use per study:
    • Known or suspected hyperkalemia
    • No medical history available
    • Signs of increased intracranial pressure
    • Chronic neuromuscular disease
    • Crush injury
    • Non-acute burns
    • Globe injury
    • To avoid a second dose of succinylcholine
  • No paralytic agent was mandated, but succinylcholine continued to be first-choice agent.
  • Data form completed by intubator immediately after intubation, which included:
    • Patient's name, age, gender
    • Paralytic used
    • Reason for use
    • Time from administration to paralysis
    • Serum K at time of intubation
    • Need for BVM ventilation
    • Pulse ox readings during intubation
    • Complications


Patient Demographics

  • Mean age: 46 years old
    • Range: days old-96 years old
  • Male: 63%

Inclusion Criteria

  • Every patient intubated in the ED from January 1, 1998 to December 31, 1998 was eligible for enrollment

Exclusion Criteria

  • No exclusion criteria noted


Two cohort RSI groups, one receiving Rocuronium 1.0 mg/kg and the other receiving Succinylcholine at the discretion of the physician


N= 521 patients who received RSI in the ED

  • 382 (73%) received succinylcholine
  • 138 (26%) received rocuronium
Common Indications for Rocuronium Use Number of Patients (%)
Suspected hyperkalemia 53 (38%)
    Chronic renal failure 28
    Rhabdomyolysis 6
Lack of medical history 43 (31%)
Known hyperkalemia 11 (8%)
Neuromuscular disease 11 (8%)
  • 34 patients had recorded hyperkalemia (>5 mmol/L) before intubation
    • Rocuronium given to 23 of these patients

Common sedative agents used:

  • Etomidate: 464 patients (89%), mean dose 0.29 mg/kg
  • Midaolam: 12 patients(2%), mean dose 0.09 mg/kg
  • Obtunded--no sedative used: 15 patients (3%)
  • No sedation recorded: 14 patients (2%)

Criticisms & Further Discussion


  • Without specific inclusion/exclusion criteria, physicians were allowed to hand-pick patients to include in the study, introducing the possibility for selection bias.
  • Patients were not randomized, and physicians were not blinded to medication choice.
    • Satisfaction score and estimated time to paralysis may be biased due to physician's knowledge of the medication.
    • Given the potential adverse effects of succinylcholine, a standard randomized and blinded trial would be nearly impossible given this clinical question.

Clinical Significance

  • Onset of paralysis was only directly measured in 33% patients, with the rest being estimated by the person performing the intubation
    • Significant difference (p=0.04) was calculated only for the measured values, but no statistical significance was calculated for estimated values
    • Although statistical significance of onset time was established, clinical significance is unclear as there were no incidences of desaturation in either group
  • Satisfaction score demonstrated a statistical significance of p <0.01
    • While this value is clearly statistically significant, clinical significance is unclear. There was only one clinically significant complication, and it occurred in the succinylcholine group.
    • Physicians were not asked to specify why they designated their satisfaction rating for each paralytic agent used

Further Discussion

  • The one complication in this study was seen in a trauma patient with unknown history and no clinical indication for hyperkalemia
    • Physicians must have a high clinical suspicion for hyperkalemia
  • Patients given rocuronium had more body movements and longer time to paralysis than patients in the succinylcholine group
    • While the mean dose of rocuronium used in this study was 1.0 mg/kg, newer studies suggest that when a dose of 1.2 mg/kg is given, the time to achieving optimum paralysis approaches that of succinylcholine [1]
  • The clinical question posed in this study was very broad and lacked specificity. Therefore, we cannot draw specific conclusions about which paralytic agent is better, just to say that rocuronium and succinylcholine both provide fast and reliable paralysis for RSI in the ED.

See Also

External Links



  1. Herbstritt A. BET 3: Is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation. Emerg Med J 2012; 29(3): 256-9.