What are the recommended medications for Rapid Sequence Intubation (RSI)?

Recommended Medications for Rapid Sequence Intubation (RSI)

For rapid sequence intubation, a combination of a sedative-hypnotic agent and a neuromuscular blocking agent (NMBA) should be administered in rapid succession, with strong evidence supporting the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. 1

Core Medication Components for RSI

Sedative-Hypnotic Agents (Induction)

The 2023 Society of Critical Care Medicine guidelines provide clear recommendations for induction agents:

• Etomidate: 0.3 mg/kg IV

  • Advantages: Hemodynamic stability, rapid onset
  • Considerations: Potential adrenal suppression (though guidelines suggest against routine corticosteroid administration following etomidate) 1

• Ketamine: 1-2 mg/kg IV

  • Advantages: Maintains hemodynamic stability, provides analgesia
  • Best for: Patients with bronchospasm or asthma 1

• Propofol: 1-2.5 mg/kg IV

  • Caution: May cause hypotension, especially in hemodynamically unstable patients
  • Better suited for elective procedures 1

The guidelines suggest there is no significant difference between etomidate and other induction agents regarding mortality or hypotension risk (conditional recommendation, moderate quality evidence) 1.

Neuromuscular Blocking Agents (Paralysis)

The guidelines strongly recommend administering an NMBA when a sedative-hypnotic agent is used for intubation (strong recommendation, low quality evidence) 1:

• Succinylcholine: 1-1.5 mg/kg IV

  • Advantages: Rapid onset (30-60 seconds), short duration (5-10 minutes)
  • Contraindications: Hyperkalemia, burns >24 hours old, crush injuries, neuromuscular disorders, malignant hyperthermia history 2

• Rocuronium: 0.9-1.2 mg/kg IV

  • Advantages: No hyperkalemia risk, suitable when succinylcholine is contraindicated
  • Disadvantage: Longer duration of action (30-40 minutes) 2

The guidelines suggest either rocuronium or succinylcholine can be used when there are no contraindications to succinylcholine (conditional recommendation, low quality evidence) 1.

RSI Medication Administration Sequence

1. Pre-oxygenation (3-5 minutes before medication administration)

   • Consider medication-assisted preoxygenation for agitated patients 1

2. Positioning

   • Head and torso inclined (semi-Fowler) position recommended 1

3. Premedication (optional, based on clinical scenario)

   • Atropine: Consider for children to prevent bradycardia
   • Lidocaine: 1-2 mg/kg IV for ICP protection 30 seconds to 5 minutes before airway instrumentation 1

4. Induction agent administration

   • Administer selected sedative-hypnotic agent
   • Critical point: A sedative-hypnotic agent should always be given when using an NMBA (best practice statement) 1

5. Neuromuscular blocker administration

   • Administer immediately after induction agent
   • Wait 45-60 seconds for optimal intubating conditions 2

6. Intubation

   • Perform laryngoscopy and endotracheal tube placement

Special Considerations

Hemodynamically Unstable Patients

• Etomidate or ketamine preferred over propofol
• Recent evidence suggests etomidate may produce less hypotension than ketamine in patients with shock or sepsis 3

Patients with Head Injury/Increased ICP

• Consider lidocaine premedication
• Etomidate may be preferred for its neuroprotective properties 1

Contraindications to Succinylcholine

• Use rocuronium at higher doses (1.0-1.2 mg/kg) when succinylcholine is contraindicated 1
• Consider having sugammadex available when using rocuronium 1

Common Pitfalls to Avoid

1. Omitting the sedative agent: Always administer a sedative-hypnotic agent with an NMBA to prevent awareness during paralysis 1

2. Inadequate dosing: Underdosing induction agents or NMBAs can lead to difficult intubating conditions and failed attempts

3. Inappropriate agent selection: Failing to consider patient-specific factors (hemodynamic status, comorbidities, contraindications)

4. Delayed sequence: Waiting too long between induction and paralytic administration can lead to suboptimal conditions

5. Neglecting positioning: The semi-Fowler position is recommended over supine for better intubating conditions 1

The evidence strongly supports using both a sedative-hypnotic agent and an NMBA for RSI, with medication selection tailored to the patient's clinical condition. The 2023 Society of Critical Care Medicine guidelines provide the most current and comprehensive recommendations for RSI medication selection.