Six FOAMed sources dropped on the same question this week, and it's the one we all thought was settled: rocuronium or succinylcholine? Except the conversation has moved. Nobody's really arguing about onset time anymore. What we're actually arguing about is whether your paralyzed patient is awake, and whether the sedation plan you scribbled on a glove is going to hold for the next 45 minutes. If you push roc and walk away, this one's for you.
The Slogan Is Not a Plan
"Roc rocks, sux sucks" is a great T-shirt. It's a lousy clinical framework.
The case for rocuronium is real: no hyperkalemia risk, no fasciculations, no bradycardia in kids, no worry about the crush injury or the burn patient or the dialysis no-show. At 1.2 mg/kg, onset is close enough to succinylcholine that the difference is measured in seconds most of us can't reliably perceive at the bedside. Multiple RSI series and meta-analyses have shown comparable first-pass success when roc is dosed appropriately. If you've been trained in the last decade, roc is probably your default, and that default is defensible.
But defensible isn't the same as thoughtless. The move away from succinylcholine was partly about safety (real) and partly about convenience (also real, honestly — nobody misses drawing up sux from the fridge). What got lost in the migration is that succinylcholine's short duration was a feature, not a bug. When your paralytic wears off in 8 to 10 minutes, you get a built-in checkpoint: is this patient sedated, or are they thrashing? Roc doesn't give you that checkpoint. Roc gives you 45 to 60 minutes of pharmacologic silence.
The Sedation Gap Nobody Wants to Talk About
Here's the uncomfortable data point. Studies looking at time-to-post-intubation sedation in the ED — including work summarized by ACEP Now and the REBEL EM review this week — consistently show a gap. Median times from intubation to a running sedative infusion range from around 15 to over 30 minutes in many departments. That's after the induction agent (etomidate, ketamine, propofol) has already peaked and started to wear off, while your long-acting NMB is doing exactly what you paid it to do.
If you gave 20 mg of etomidate for a 90 kg patient, that hypnotic effect is fading by minute 7 to 10. Your roc is going nowhere. Do the math.
Awareness with paralysis in the ED is not a rare theoretical concern. Pappal et al. (the ED-AWARENESS study, 2021) found roughly 3% of mechanically ventilated ED patients had explicit recall of paralysis. Rocuronium use was independently associated with awareness. That's not an artifact — that's the predictable consequence of a long-acting paralytic outlasting a short-acting induction agent when nobody bridges the gap.
Ask any patient who's experienced it what it was like. Then decide how comfortable you are with your current workflow.
FARSI, VAFI, and Thinking Past Laryngoscopy
The LITFL crew has been beating this drum with FARSI (Facilitated Awake Rapid Sequence Intubation) and VAFI (Ventilator-Assisted Facilitated Intubation) concepts, and while those are specific techniques for specific patients, the underlying philosophy applies universally: the intubation doesn't end when the tube passes the cords.
The framework we should be teaching residents is the intubation-to-sedation arc. Your drug choices at minute zero commit you to a plan at minute five, minute fifteen, and minute forty-five. If you push roc, you have implicitly committed to:
- A sedative infusion running before the paralytic peaks
- An analgesic on board (paralysis without analgesia is torture, full stop)
- A plan for re-dosing induction if the infusion is delayed by pharmacy, IV access, or the CT scanner
If you can't commit to all three, you either need to fix your system or reconsider whether roc is the right choice for that particular resuscitation.
So Is There Still a Case for Sux?
Yes, and we're going to lose friends saying it.
Succinylcholine still has a role in:
- The undifferentiated seizing patient where you need a rapid neuro re-exam. Waiting 45 minutes for roc to wear off to reassess status epilepticus is a genuinely bad plan.
- The predicted difficult airway where you want the option to bag the patient back to spontaneous ventilation if things go sideways. Sugammadex changes this calculus if it's actually available and drawn up (be honest about your department), but in many EDs it isn't at the bedside.
- The department where post-intubation sedation is reliably delayed. If your system consistently has a 20-minute sedation lag and you can't fix it tonight, a shorter-acting paralytic is a harm-reduction strategy, not a failure of modernity.
The contraindication list for sux is real and you should know it cold: hyperkalemia, known or suspected, including the subacute denervation states (stroke >72 hours, burn >72 hours, prolonged immobilization, neuromuscular disease). But "I might not remember all the contraindications" is not itself a contraindication.
The Pre-Intubation Sedation Checklist
Here's what we've landed on. Before the paralytic goes in, the following are drawn up, labeled, and at the bedside:
- Analgesic — fentanyl bolus and/or infusion ready. Post-intubation pain control is not optional.
- Sedative infusion — propofol or ketamine bag spiked, tubing primed, pump programmed. Not "on the way from pharmacy." At the bedside.
- Push-dose sedation bridge — a syringe of ketamine or propofol you can give within 60 seconds of tube confirmation to cover the gap while the infusion titrates up.
- Named person responsible — someone in the room owns "sedation" the way someone else owns "airway." If nobody owns it, it doesn't happen.
Draw it up before you push the roc. Every time.
The Bottom Line
- The paralytic debate isn't really about onset or first-pass success anymore. It's about what happens in the 45 minutes after the tube is confirmed.
- Rocuronium is a reasonable default for most RSI, but it commits you to an aggressive, pre-planned post-intubation sedation strategy.
- Awareness with paralysis is real, common enough to matter, and preventable. ED-AWARENESS put the number around 3%. Own it.
- Sux still has a role in specific scenarios: seizing patients needing neuro reassessment, predicted difficult airways without reliable sugammadex, and departments with structural sedation delays.
- Draw up post-intubation sedation before you push the paralytic. Sedative infusion, analgesic, push-dose bridge, and a named owner. No exceptions.
Sources
- REBEL EM. Rocuronium vs Succinylcholine for RSI: Awareness, Paralysis, and Post-Intubation Sedation. https://rebelem.com/rocuronium-vs-succinylcholine-rsi/
- ACEP Now. Pharmacologic Management of the Post-Intubation Patient in the ED. https://www.acepnow.com/article/pharmacologic-management-of-the-post-intubation-patient-in-the-ed/
- Life in the Fast Lane. VAFI and FARSI. https://litfl.com/vafi-and-farsi/
- Pappal RD, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Emergency Department Patients. Ann Emerg Med. 2021;77(5):532-544.
- Korinek JD, et al. Comparison of rocuronium and succinylcholine for rapid sequence intubation of emergency department patients. Cochrane review and subsequent meta-analyses (2015, updated).
Disclaimer: The content on Against Medical Advice — including all podcast episodes, blog posts, and videos — is intended for educational purposes only. It does not constitute medical advice, diagnosis, or treatment. Listening to or reading this content does not establish a doctor-patient relationship. Always consult a qualified healthcare provider for medical decisions. The views expressed are those of the hosts and do not represent their employers, residency programs, or affiliated institutions.