The decision is made to emergently intubate the patient and you prepare for RSI. Traditionally, succinylcholine is dosed 1—1. Succinylcholine generally takes 45—60 seconds for onset of laryngeal paralysis. A year-old female with recent burns to the lower extremities after being caught in a house fire four days ago presents to the ED for altered mental status and somnolence.
The family states that they found her in her bedroom next to an empty bottle of vodka. Her Glasgow coma scale is 7 and she presents with normal-sized but sluggish pupils. Succinylcholine has been traditionally used as a first-line paralytic due to its quick onset of action and short half-life.
However, succinylcholine has major side effects, including hyperkalemia, malignant hyperthermia, fasciculations and bradycardia. These effects are seen most significantly in patients with prior stroke, baseline neuromuscular disease and recent burn victims. Rocuronium has a much more limited side effect profile, and is limited to hepatotoxicity.
A year-old male with an unknown medical history is found down on the sidewalk covered in a pool of vomitus and surrounded by his belongings. Which paralytic would you like to use? Intubation conditions: A Cochrane review evaluated whether rocuronium could provide similar intubating conditions to succinylcholine for RSI. When higher doses of rocuronium 1. This review shows that rocuronium can be effectively used to provide proper intubating conditions in patients where succinylcholine is contraindicated.
In addition, rocuronium has a significantly smaller side effect profile and may be a safer drug for RSI and induction for the general population. Apnea time: Rocuronium has a second longer safe apnea time when compared to succinylcholine. Multiple studies evaluate this topic and determined the fasciculation scores after injection of succinylcholine and rocuronium. Succinylcholine had significantly higher fasciculation scores than rocuronium. Rent article Rent this article from DeepDyve.
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Dewachter , P. Rocuronium or suxamethonium aka succinylcholine? Both roc and sux bind to nicotinic aceytlcholine receptors at the neuromuscular junction, thus preventing motor neurones from triggering action potentials in skeletal muscle. Suxamethonium is really just two acetylcholine molecules stuck together.
It acts as a depolarising muscle relaxant — hence fasciculations occur prior to muscle relaxation. Rocuronium is an analogue of vecuronium, an aminosteroid. It acts as a non-depolarising muscle relaxant.
Sux is rapidly hydrolysed thanks to the action of plasma and liver pseudocholinesterases but not in patients susceptible to suxamethonium apnoea , which occurs in people with rare variations of the pseudocholinesterase gene. Sux is typically given at a dose of 1 to 1. In infants a higher dose of 1. It can also be given IM, but at a higher dose e. The dose of roc used in RSI varies from 0.
I suggest using 1. Except in patients with poor perfusion states, good intubating conditions are typically achieved after 45 to 60 seconds with suxamethonium. Proponents of sux cite this as a major advantage over roc. Traditionally roc is considered to have a slower onset of action than sux. Indeed, this is true if you use lower doses like 0. However, if a dose of 1. There is no doubt that roc renders patients paralysed for much longer than sux.
Optimal intubating conditions probably last about 5 minutes after giving an RSI dose of sux , although time to complete recovery is more like 10 minutes. Like the onset, the duration of effect for rocuronium depends on the dose administered. Recovery may occur as early as 30 minutes following a dose of 0. In the resus room RSI, keeping the patient paralysed is an advantage : while you frantically work your way through your back up plans the last thing you need is the patient fighting your attempts at ventilation or pushing your scalpel-wielding hand away in the midst of a hypoxic spiral into the abyss….
Remember to use apneic oxygenation and the other tips shown in the videos featured in Own the Airway! Anyway, roc can now be reversed in about 2.
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