Rocuronium versus succinylcholine in air medical rapid-sequence intubation

It is not known how rocuronium compares with succinylcholine in its effect on intubation success during air medical rapid-sequence intubation (RSI).

To examine the impact of succinylcholine use on the odds of successful prehospital intubation.

We performed a retrospective analysis of a critical care transport service administrative database containing patient encounters from 2004 to 2008. Rotor transports of patients ≥ 18 years old, requiring airway management (intubation or backup airway: laryngeal mask airway, Combitube, or cricothyrotomy), and receiving either rocuronium or succinylcholine were included in the analysis. Patients receiving both drugs were excluded. Multiple imputation was used to account for records that were missing data elements. A propensity score based on patient and encounter characteristics was calculated to control for the effect of clinical factors on the choice of drug by air medical personnel. Logistic regression was used to assess the impact of succinylcholine use on the odds of first-attempt intubation. Ordinal logistic regression was used to assess the impact of succinylcholine on the number of attempts required to intubate (1, 2, or ≥ 3 or backup airway).

A total of 1,045 patients met the criteria for analysis; 761 (73%) were male, and the median age was 41 years (interquartile range 26-56). Eight hundred seventy-six (84%) were transported from the scene, and 484 (46%) received succinylcholine. Six hundred twelve (59%) were intubated on the first attempt, 322 (31%) required two attempts, 69 required three or more attempts (7%), and 42 required a backup airway (4%). After propensity score adjustment, succinylcholine was associated with a higher incidence of first-attempt intubation (odds ratio 1.4, 95% CI 1.1-1.8), as well as improved odds for requiring fewer attempts to intubate (odds ratio 1.5, 95% CI 1.2-1.9), as compared with rocuronium.

Rapid-sequence intubation was more successful with fewer attempts in patients intubated by air medical crews with succinylcholine as opposed to rocuronium. Prospective, randomized studies are needed to confirm these findings and to explore the impact of succinylcholine on the outcomes of air medical-transported patients. Key words: airway management; critical care; emergency medical services; neuromuscular blockade; succinylcholine; rocuronium; rapid-sequence intubation; intubation; air medical transport.