UMEM Educational Pearls

Category: Toxicology

Title: Rocuronium vs Succinylcholine

Keywords: rocuronium, succinylcholine (PubMed Search)

Posted: 3/17/2011 by Fermin Barrueto, MD (Updated: 4/12/2024)
Click here to contact Fermin Barrueto, MD

Most have converted from succinylcholine to rocuronium for their choice of paralytic in RSI. Succinylcholine-induced hyperkalemia secondary to muscle fasciculations is considered usually clinically insignificant though there may be a hyperkalemic renal patient that this may tip them over. The fasciculations also may worsen traumatic long bone fractures.  Here is the argument in a head to head comparison:




Rocuronium   Winner  
Onset 1-1.5min 1.5-3min



Recovery Index






Mild S


Yes No Roc


Yes - Released None Roc
Pulse Rare Brady

Rare Tachy at high dose


Duration = injection of drug to 25% recovery of single twitch height (clinically relevant recovery in ED - essentially breathing may return)

Recovery Index = time from 25% to 75% recovery of single twitch height

The main reason succinylcholine was utilized was because of its fast onset and short duration. Rocuronium is comparable enough to succinylcholine in these characteristics tilting the overall benefits to rocuronium. If the FDA ever approves it, suggamadex is a possible reversal agent for rocuronium - currently used in Europe. Imagine having that in your RSI kit.