Elsevier

The Journal of Emergency Medicine

Volume 17, Issue 4, July–August 1999, Pages 611-616
The Journal of Emergency Medicine

Original Contributions
Rocuronium for rapid sequence intubation of emergency department patients

Presented at the ACEP Scientific Assembly, San Diego, California, 1998.
https://doi.org/10.1016/S0736-4679(99)00046-3Get rights and content

Abstract

Rocuronium is a recently synthesized non-depolarizing neuromuscular blocking agent (NMBA) that has been demonstrated to have a faster onset of action than any other non-depolarizing NMBA. Although widely studied in the operating room, there are no reports regarding its use for emergent tracheal intubation in the emergency department (ED). The purpose of this study was to evaluate the use of rocuronium for rapid sequence intubation (RSI) in ED patients. An intubation data collection form was completed prospectively for any patient receiving rocuronium for RSI in the ED from July 1–December 31, 1997. Two hundred eighty-eight patients were intubated in the ED over this six-month period, of whom 261 (91%) underwent RSI. Fifty-eight of the patients undergoing RSI received rocuronium for paralysis (22%). The most common reason reported for use of rocuronium was a concern regarding hyperkalemia (53%). The mean dose used was 1.0 ± 0.2 mg/kg. The mean onset to paralysis was 45 ± 15 s. Of the complications reported, none appeared to be related to rocuronium. Use of rocuronium in the ED setting appears useful.

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,

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