What is the recommended dosage and administration rate for rapid sequence intubation (RSI) medications, such as etomidate (amidate) and succinylcholine?

From the Guidelines

For rapid sequence intubation (RSI), etomidate should be administered at 0.3 mg/kg IV as a single dose, while succinylcholine is given at 1.5-2 mg/kg IV, with the sedative given first, followed immediately by the paralytic agent, as recommended by the most recent guidelines 1. The administration rate for these medications is critical, and they should be given in rapid sequence to facilitate intubation.

• Etomidate has a rapid onset of action, typically within 30-60 seconds, making it suitable for emergency intubations.
• Succinylcholine produces paralysis within 45-60 seconds, with effects lasting approximately 5-10 minutes. Key considerations for RSI medication administration include:
• Proper dosing to avoid underdosing, which may result in inadequate conditions for intubation, or overdosing, which increases the risk of adverse effects.
• Etomidate is preferred in many emergency settings due to its minimal effects on hemodynamics, but it should be used cautiously in septic patients as it may suppress adrenal function.
• Succinylcholine should be avoided in patients with hyperkalemia, burns, crush injuries, or neuromuscular disorders due to the risk of dangerous potassium elevation. The choice of medication and administration rate should be guided by the patient's medical history and clinical situation, as well as the availability of resuscitation equipment and the ability to pre-oxygenate the patient adequately before medication administration 1.

From the FDA Drug Label

The average dose required to produce neuromuscular blockade and to facilitate tracheal intubation is 0.6 mg/kg Succinylcholine Chloride Injection given intravenously. The optimum dose will vary among individuals and may be from 0.3 to 1.1 mg/kg for adults. Following administration of doses in this range, neuromuscular blockade develops in about 1 minute; maximum blockade may persist for about 2 minutes, after which recovery takes place within 4 to 6 minutes.

The recommended dosage for rapid sequence intubation (RSI) with succinylcholine is 0.6 mg/kg given intravenously, with a range of 0.3 to 1.1 mg/kg for adults. The administration rate is not explicitly stated, but the onset of effect is typically observed in about 1 minute.

• The dose for pediatric patients is different, with 2 mg/kg for infants and small pediatric patients, and 1 mg/kg for older pediatric patients and adolescents.
• It is essential to individualize the dose and carefully monitor the patient's response to avoid overdose and detect potential complications 2.

From the Research

Rapid Sequence Intubation Medications

The recommended dosage and administration rate for rapid sequence intubation (RSI) medications, such as etomidate and succinylcholine, vary depending on the specific clinical setting and patient population.

• Etomidate is often used at a dose of 0.1 to 0.3 mg/kg intravenously (IV) 3
• Rocuronium has been suggested as an alternative to succinylcholine for intubation, with a dose of at least 0.6 mg/kg 4
• Succinylcholine is typically used at a dose of at least 1 mg/kg 4

Administration Rate

The administration rate for RSI medications is typically rapid, with the goal of achieving intubation as quickly as possible.

• Etomidate has a rapid onset of action, with intubation typically occurring within 1-2 minutes after administration 5, 3
• Rocuronium also has a rapid onset of action, with intubation typically occurring within 1-2 minutes after administration 4
• Succinylcholine has a very rapid onset of action, with intubation typically occurring within 30-60 seconds after administration 4

Hemodynamic Stability

The use of etomidate for RSI has been associated with hemodynamic stability, with minimal changes in blood pressure and heart rate 5, 3.

• Rocuronium has also been shown to be associated with hemodynamic stability, although it may cause more histamine release than etomidate 4
• Succinylcholine can cause significant hemodynamic changes, including hypotension and bradycardia, particularly in patients with certain medical conditions 4

Intubating Conditions

The quality of intubating conditions is an important factor in the success of RSI.

• Succinylcholine has been shown to be superior to rocuronium in achieving excellent intubating conditions, particularly when used with thiopental as the induction agent 4
• Etomidate has been shown to be effective in achieving intubation, although it may not provide the same level of muscle relaxation as succinylcholine or rocuronium 5, 3