An interesting new study was published looking at in-hospital mortality in TBI patients who received succinylcholine or rocuronium for RSI in the ED.

What They Did

• Retrospective cohort study
• 233 patients (149 received succinylcholine, 84 received rocuronium)
• Groups were well matched overall (roc group was older, more hypotension in sux group)
• Within the two groups, patients were separated based on head Abbreviated Injury Score (scores of 4 or 5 were considered severe)
• The authors controlled for a lot of confounding factors

What They Found

• Overall, mortality was the same in each group (23%)
  • Mortality within the roc group was the same irrespective of head AIS
  • Mortality within the sux group was significantly higher in the subset of patients with higher head AIS (OR 4.1, 95% CI 1.18-14.12, p = 0.026)

Application to Clinical Practice

• Succonylcholine may increase mortality in severe TBI patients undergoing RSI in the ED compared to rocuronium
• The confidence interval was wide and these findings need to be confirmed in a prospective study
• Though the patients were well matched and the authors controlled for many variables, it still is difficult to pinpoint one intervention as the cause for mortality in critically ill patients (eg, etomidate + sepsis)
• With proper rocuronium dosing, intubating conditions are similar to succinylcholine. So if there is a potential for increased mortality in severe TBI patients with sux, rocuronium seems to provide a safer alternative.

References

Patanwala AE, et al. Succinylcholine is associated with increased mortality when used for rapid sequence intubation of severely brain injured patients in the emergency department. Pharmacotherapy 2016;36(1):57-63. [PMID 26799349]

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