Emergency department use of neuromuscular blocking agents in children

There is no ideal neuromuscular blocking agent with a rapid onset and ultra-short duration of action with a good safety profile in children. Rocuronium, vecuronium, rapacuronium, and succinylcholine are currently the neuromuscular blocking agents most suitable for children who require RSI in ED settings. Succinylcholine is the only agent with rapid onset and ultra-short duration of action; however, it has many potential side effects, of which some (albeit rare) may be fatal. In select situations, some emergency physicians may decide that the benefits of succinylcholine outweigh the risks; however, others may choose a nondepolarizing agent as their drug of choice for RSI. Rocuronium has an excellent safety profile and a rapid onset of action similar to succinylcholine. Despite a longer duration of action, rocuronium is the preferred agent for RSI in children by many physicians. For EDs that do not have access to rocuronium, vecuronium is frequently the agent of choice for RSI in children. Despite its longer onset of action and recovery, its side effects are minimal when compared to succinylcholine. If further studies confirm the safety profile of rapacuronium, its rapid onset and short duration of action will likely make it the neuromuscular blocking agent of choice for RSI.