Original ContributionsRocuronium for rapid sequence intubation of emergency department patients
Introduction
Tracheal intubation is a lifesaving intervention that is performed daily in emergency departments (EDs) across the country. Recent literature has indicated that rapid sequence intubation (RSI) with neuromuscular blocking agents (NMBAs) has become the most common method emergency physicians use to achieve tracheal intubation 1, 2, 3, 4, 5. A recent survey found that virtually all EDs associated with emergency medicine training programs stock succinylcholine for use in RSI (6). A 1-year study at our institution demonstrated that 92% of patients undergoing RSI in the ED received succinylcholine for paralysis (1).
From a pharmacodynamic standpoint, succinylcholine’s extremely rapid onset of action and its short duration of action make it the ideal NMBA for RSI. Unfortunately, succinylcholine can cause such adverse effects as fasciculations, increased intracranial pressure, and increased intra-ocular pressure 7, 8. While many of these side effects are of little clinical significance, succinylcholine also can have some potentially life-threatening effects 7, 8. One of its potentially most dangerous side effects is the intracellular release of potassium from myocytes, resulting in a transient state of hyperkalemia (9). While this is also of little clinical significance in most patients, there are some in whom succinylcholine can cause massive hyperkalemia and thus precipitate severe dysrhythmias and cardiac arrest. There are numerous case reports of succinylcholine-related cardiac arrest associated with specific medical and traumatic conditions such as muscular dystrophy, subacute spinal cord injuries, denervation syndromes, severe infections, extensive burns, and massive trauma 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21.
In addition, in patients who present to the ED with clinically significant hyperkalemia, even the normal physiologic release of potassium produced by succinylcholine can cause life-threatening dysrhythmias. Because of these adverse effects and risks associated with succinylcholine, extensive laboratory work has been directed at the development of a non-depolarizing NMBA with a speed of onset comparable to succinylcholine’s but with none of its adverse effects. Rocuronium, a structural analog of vecuronium, was recently synthesized and has been demonstrated to have the fastest onset of any non-depolarizing NMBA 22, 23, 24, 25, 26, 27. It has been extensively studied in both the laboratory and the operating room. Its onset time approaches that of succinylcholine, it has virtually no clinically significant cardiovascular effects, and it does not produce hyperkalemia 24, 25, 26, 27, 28, 29. But despite the large body of literature on rocuronium, there are no reports regarding its use for RSI in the ED setting. The purpose of this study was to evaluate rocuronium for RSI of ED patients.
Section snippets
Materials and methods
The University of California’s Davis Medical Center is an urban Level 1 Trauma Center with an annual ED census of 60,000. Each year, approximately 600 patients are intubated in the ED, the vast majority by emergency residents under the supervision of an attending emergency physician. Our ED began stocking rocuronium in June 1997, and all emergency medicine residents and attendings were instructed on its phamacological properties and indications for its use through a series of formal lectures.
Results
Over the 6-month study period, 288 patients were intubated in the ED. Of the total, 261 (91%) underwent RSI. Twenty-seven patients (9%), most of them in cardiac arrest, were intubated orally without the aid of NMBAs. Of the 261 patients who underwent RSI, 200 received succinylcholine and three received vecuronium. Rocuronium was used for the remaining 58 patients (22%) who underwent RSI. Most patients who received rocuronium were intubated for medical conditions (86%) ( Table 1). More than 90%
Discussion
While succinylcholine remains our first line agent for RSI of ED patients, it has several contraindications and can result in some potentially life-threatening complications. Previously, we used vecuronium for RSI when there was a contraindication to succinylcholine. However, its relatively long onset of action compared with succinylcholine invariably necessitated BVM ventilation before intubation. This is highly undesirable in emergency settings because of the risk of gastric insufflation,
References (39)
- et al.
Airway management in the emergency departmenta one-year study of 610 tracheal intubations
Ann Emerg Med
(1998) - et al.
Rapid sequence intubation in the emergency department
J Emerg Med
(1995) - et al.
Airway management practices in emergency medicine residencies
Am J Emerg Med
(1995) - et al.
Neuromuscular blocking agents in the emergency department
J Emerg Med
(1996) Suxamethonium-induced cardiac arrest in unsuspected pseudohypertrophic muscular dystrophy. Case report
Br J Anaesth
(1971)- et al.
Double-blind comparison of two doses of rocuronium and succinylcholine for rapid-sequence intubation
J Clin Anesth
(1997) - et al.
Complication rate of emergency department intubationsfirst report of the national emergency airway registry (NEAR)
Acad Emerg Med
(1997) - et al.
Rapid-sequence intubation at an emergency medicine residencysuccess rate and complications during a two-year period
Acad Emerg Med
(1996) - et al.
Rapid-sequence induction technique for orotracheal intubation of adult nontrauma patients in a community hospital setting
Ann Emerg Med
(1995) - et al.
Adverse effects of depolarising neuromuscular blocking agents. Incidence, prevention and management
Drug Safety
(1994)
Pathophysiology of hyperkalemia induced by succinylcholine
Anesthesiology
Hyperkalemic cardiac arrest during anesthesia in infants and children with occult myopathies
Clin Pediatr
Succinylcholine-induced cardiac arrest in unsuspected Duchenne muscular dystrophy
Can Anaesth Soc J
Succinylcholine-induced cardiac arrest in children with undiagnosed myopathy
Can J Anaesth
Succinylcholine, paraplegia, and intraoperative cardiac arrest. A case report
J Bone Joint Surg Am
Paraplegiasuccinylcholine-induced hyperkalemia and cardiac arrest
Arch Phys Med Rehabil
Paraplegia, succinylcholine and cardiac arrest
Anesthesiology
Cardiac arrest after succinylcholine administration in a pregnant patient recovered from Guillain-Barre syndrome
Anesthesiology
Hyperkalemic cardiac arrest after succinylcholine administration in a child with purpura fulminans
Anesthesiology
Cited by (15)
Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation
2003, American Journal of Emergency MedicineCitation Excerpt :Medications used for paralysis and sedation have been associated with specific problems. In cases of suspected hyperkalemia, succinylcholine should be avoided but rocuronium has been used successfully.9-11 Adrenal dysfunction has been reported with use of etomidate.
The failed intubation attempt in the emergency department: Analysis of prevalence, rescue techniques, and personnel
2002, Journal of Emergency MedicineEffect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial
2019, JAMA - Journal of the American Medical AssociationFactors associated with post-intubation hypotension in an emergency department: A retrospective observational study
2017, Journal of the Medical Association of Thailand