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

Objectives: Succinylcholine and rocuronium are neuromuscular blocking agents used in the emergency department (ED) during rapid sequence intubation (RSI). Very few studies have been conducted to determine which agent is preferred for children. This study analyzed outcomes of death, post-traumatic stress disorder (PTSD) and malignant hyperthermia for children administered succinylcholine versus rocuronium for RSI in the ED. Methods: This retrospective, propensity-matched study utilized the TriNetX database. Cohorts included children less than or equal to 17 years of age, given a paralytic agent plus etomidate or ketamine during intubation in the ED from 2004 to 2024. Cohorts were further stratified by the administration of succinylcholine or rocuronium. The outcomes measured were death, PTSD, and malignant hyperthermia. Propensity matching was done for demographics and pre-existing conditions. Results: Before propensity matching, 2095 pediatric patients were identified. After propensity matching, 706 patients were identified in each cohort. After propensity matching, children administered succinylcholine had a lower rate of death (5.7% vs. 8.9%, RR: 0.65, 95% CI 0.43-0.93, P =0.019) but no significant difference in PTSD (2.6% vs. 3.7%, RR: 0.71, 95% CI 0.32-1.68, P =0.399). There was no significant difference in malignant hyperthermia. Subgroup analysis suggests that succinylcholine and etomidate were the best combination of drugs for RSI. Conclusions: Mortality rates were lower for children administered succinylcholine for RSI when compared with rocuronium. This study demonstrates a potential association between succinylcholine use and favorable RSI outcomes in the ED, though further prospective studies are needed.