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Succinylcholine Versus Rocuronium for Pediatric Rapid Sequence Intubation in the Emergency Department

Donna Mendez1, John Zatarain1, Krishna Paul1

  • 1Departments of Emergency Medicine.

Pediatric Emergency Care
|January 5, 2026
PubMed

Insights

In pediatric emergency medicine, succinylcholine use during rapid sequence intubation (RSI) was associated with lower mortality compared to rocuronium. This finding suggests succinylcholine may be a preferred agent for pediatric RSI in the ED.

Area of Science:

  • Pediatric Emergency Medicine
  • Pharmacology
  • Critical Care

Background:

  • Neuromuscular blocking agents like succinylcholine and rocuronium are crucial for rapid sequence intubation (RSI) in emergency departments (ED).
  • Limited research exists comparing the safety and efficacy of these agents specifically in pediatric populations undergoing RSI.
  • Key outcomes of interest include mortality, post-traumatic stress disorder (PTSD), and malignant hyperthermia.

Purpose of the Study:

  • To compare the outcomes of death, PTSD, and malignant hyperthermia in children receiving succinylcholine versus rocuronium for RSI in the ED.
  • To identify potential differences in adverse events associated with these neuromuscular blocking agents in pediatric patients.

Main Methods:

  • A retrospective analysis of the TriNetX database was conducted, including pediatric patients (≤17 years) undergoing ED intubation between 2004 and 2024.
  • Patients received either succinylcholine or rocuronium as a paralytic agent, often in conjunction with etomidate or ketamine.
  • Propensity matching was employed to control for demographic and pre-existing condition differences between the two cohorts.

Main Results:

  • After propensity matching, 706 patients were analyzed in each cohort (succinylcholine vs. rocuronium).
  • Children receiving succinylcholine demonstrated a significantly lower mortality rate (5.7% vs. 8.9%, P=0.019).
  • No significant differences were observed in PTSD rates or malignant hyperthermia between the groups. Subgroup analysis indicated succinylcholine with etomidate as an optimal RSI drug combination.

Conclusions:

  • Succinylcholine administration was associated with reduced mortality in pediatric patients undergoing RSI in the ED compared to rocuronium.
  • The study suggests a potential benefit of succinylcholine for improving RSI outcomes in children.
  • Further prospective research is warranted to confirm these findings and guide clinical practice.
Abstract

Keywords:
Pediatric Emergency Medicinerapid sequence intubationrocuroniumsuccinylcholine

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