Succs vs Roc for RSI

Cook26 · Dec 8, 2015

One is not better than the other. They are different and can be used for different situations, which are numerous.

As far as RSI, giving an RSI dose of zemuron will give you intubating conditions in a timeframe similar to succinylcholine. The onset of sux is 30-60 seconds and roc is around 60-90. Roc does last longer but if they are sedated after then it doesn't matter.

Sometimes it just depends on who is intubating and what they prefer, although it should be patient specific based on potential adverse side effects.

Lev, MSN, RN, NP · Dec 8, 2015

I heard that roc is not as good for neuro patients such as head bleeds because it take longer to wear off. With propfol you can control their level of sedation. I would think with neuro patients you wouldnt want them too sedated.

Anna Flaxis, BSN, RN · Dec 8, 2015

Remember that Roc is not a sedative, it is a paralytic. The reason it would be concerning to use in the setting of severe neurological injury is that it provides motor paralysis for about 45 minutes, meaning that the patient can't be re-examined in that amount of time, compared to about 10 minutes for sux.

Also, Roc takes a little longer to act, so ideal intubation conditions aren't achieved as quickly as with Sux.

As mentioned above, it's not that one is "better" than the other- it's a matter of clinician preference and patient specific risks vs. benefit.

Cook26 · Dec 9, 2015

When I used to work in the neuro ICU, we pretty much always used roc for RSI for what it's worth. Although probably negligible, sux can cause a small transient increase in ICP.

At the point you need to emergency intubate, a delay in neuro assessment is usually not the priority. Also, we usually only did q1 neuro assessments, so 30 minutes wasn't that big of a deal.

As far as sedation, we did use mostly propofol because we could intermittently turn it off for proper neuro checks. For neuro pts we usually only used a versed drip for burst suppression if they were in status.

Anna Flaxis, BSN, RN · Dec 9, 2015

The ER setting is a little different, with a focus on rapid stabilization and transfer, so faster and shorter acting NMB in the initial stages may be more advantageous.

Cook26 · Dec 9, 2015

The ER setting is a little different, with a focus on rapid stabilization and transfer, so faster and shorter acting NMB in the initial stages may be more advantageous.

If they are intubated then they will be going to the unit anyway. Provided they have proper sedation, the difference is really negligible for the purposes of this discussion.

Anna Flaxis, BSN, RN · Dec 9, 2015

Sometimes they go to the OR first.

I was just pointing out some reasons clinicians may choose one over the other. A situation where it might make a difference is if the neuro intensivist wants to see the patient sooner rather than later, but then they have to wait for the NMB to wear off before they can evaluate. Sometimes they get a little cranky when they have to wait.

But yeah, the difference is really negligible in the grander scheme of things.

Nonyvole, BSN, RN · Dec 9, 2015

Docs that I currently work with prefer succs. Roc is for if there is any concern about hyperkalemia.

LV3677 · Dec 9, 2015

Like the PP stated, if there are issues about hyperkalemia, i.e., burns, then roc is the choice.

"Succinylcholine (SCh) is a depolarizing neuromuscular-blocking agent, which produce sustained opening of the nicotinic cholinergic receptor channel. Under normal conditions, post-junctional membrane depolarization results in leakage of potassium that produces an increase of 0.5 â€“ 1.0 mEq/L in serum K+ concentration. When SCh depolarizes muscle that has been traumatized (crush injury) or denervated (upper motor neuron lesion) enough K+ may leak from cells to produce systemic hyperkalemia and cardiac arrest. This susceptibility to hyperkalemia is thought to be caused by proliferation of junctional and extrajunctional cholinergic receptors."

Source: https://www.openanesthesia.org/neuromuscular_disease_succinylcholine_hyperkalemia/

AnnieOaklyRN, BSN, RN, EMT-P · Dec 13, 2015

I find most docs prefer succs for initial intubation because it only lasts about 5 minutes, so if they cannot intubate the patient they aren't totally screwed. Once the patient is intubated a longer acting paralytic will be used such as vecuronium or Rocuronium (sp), which generally last 30 minutes- 1 hour.

Annie