Rocuronium versus succinylcholine in the traumatically injured brain: a pilot study

Introduction: Acute traumatic brain injury (TBI) often requires rapid sequence intubation (RSI) to protect patients’ airways. RSI begins with pharmacologic induction, followed by paralysis with agents such as rocuronium or succinylcholine. These medications benefit from a rapid onset and a relatively short duration. Animal data has demonstrated succinylcholine may produce elevations in intracranial pressure. Previous retrospective literature demonstrated a mortality benefit favoring rocuronium. This study aimed to prospectively evaluate mortality, among other outcomes, following RSI with rocuronium compared to succinylcholine for patients presenting to the emergency department (ED) with acute TBI. Methods: This prospective, observational, single-center trial identified patients from 9/1/2018 through 9/1/2020. The study population consists of adult patients presenting to the ED of a Level 1 Trauma Center with acute TBI who underwent RSI with either succinylcholine or rocuronium. Data was collected via convenience sampling when a clinical pharmacist was present during RSI. Demographics recorded include age, sex, race, severity of TBI, injury severity score (ISS), and initial Glasgow Coma Scale (GCS). Exclusion criteria: surgical airway, pregnancy, cardiac arrest prior to or within 24 hours after RSI, or intubation attempt prior to arrival. Primary outcome evaluated was incidence of in-hospital mortality. Secondary outcomes include hospital and intensive care unit (ICU) length of stay (LOS). A sample size of 156 subjects was calculated to detect a 20% difference in mortality. Results: Of 103 patients evaluated in the study, 87 were included for analysis. Of these, 21 received rocuronium and 66 succinylcholine population. Baseline demographics were comparable between both groups with median ISS, GCS, and TBI severity non-statistically different. GCS upon arrival was 6 and 5 rocuronium and succinylcholine arms respectively (p=0.42). No statistical difference was detected in the incidence of in-hospital mortality (38.1% and 33.3%; p=0.793), in-hospital LOS (13 vs 12 days; p=0.682), or ICU LOS (7 vs 7 days; p=0.825) between the two treatment groups. Conclusions: In this prospective, observational trial no difference was observed in in-hospital mortality. ICU and hospital length of stay were similar between arms.