Recommended Induction and Paralytic Drugs for Different Rapid Sequence Intubation (RSI) Scenarios
For optimal patient outcomes during RSI, succinylcholine is the first-line paralytic agent of choice for patients with vital signs of distress, while rocuronium at doses above 0.9 mg/kg should be used when succinylcholine is contraindicated. 1 The choice of induction agent should be tailored to the specific clinical scenario, with etomidate, ketamine, and propofol being the primary options.
Scenario 1: Hemodynamically Unstable Patient
Induction Agent:
- Ketamine (1-2 mg/kg IV) - Preferred due to its sympathomimetic properties that help maintain blood pressure
- Etomidate (0.3 mg/kg IV) is an alternative option with minimal hemodynamic effects
Paralytic Agent:
- Succinylcholine (1-1.5 mg/kg IV) - First-line due to rapid onset and short duration
- Rocuronium (1.0-1.2 mg/kg IV) if succinylcholine is contraindicated
Clinical Considerations:
- Have vasopressors readily available
- Consider pre-intubation fluid bolus if not contraindicated
- Position patient in semi-Fowler position if possible 1
Scenario 2: Patient with Traumatic Brain Injury
Induction Agent:
- Etomidate (0.3 mg/kg IV) - Preferred due to minimal effect on cerebral perfusion pressure
- Ketamine (1-2 mg/kg IV) is now considered acceptable in TBI (previous concerns about increasing ICP have been largely disproven)
Paralytic Agent:
- Succinylcholine (1-1.5 mg/kg IV) - Unless contraindicated (e.g., >48 hours post-injury)
- Rocuronium (1.0-1.2 mg/kg IV) if >48 hours post-injury or other contraindication to succinylcholine
Clinical Considerations:
- Maintain head-of-bed elevation to reduce ICP
- Consider lidocaine (1.5 mg/kg IV) pretreatment to blunt ICP rise
- Avoid hypotension at all costs (maintain MAP >80 mmHg)
Scenario 3: Status Asthmaticus/Severe Bronchospasm
Induction Agent:
- Ketamine (1-2 mg/kg IV) - Preferred due to bronchodilatory properties
- Propofol (1-2 mg/kg IV) as alternative if hemodynamically stable
Paralytic Agent:
- Succinylcholine (1-1.5 mg/kg IV) - First-line choice
- Rocuronium (1.0-1.2 mg/kg IV) if contraindication to succinylcholine exists
Clinical Considerations:
- Continue bronchodilator treatments during RSI preparation
- Consider IV magnesium sulfate pre-intubation
- Prepare for potential post-intubation dynamic hyperinflation
Scenario 4: Septic Shock
Induction Agent:
- Ketamine (0.5-1 mg/kg IV) - Reduced dose due to hemodynamic instability
- Etomidate (0.15-0.3 mg/kg IV) as alternative, though concerns exist about adrenal suppression
Paralytic Agent:
- Succinylcholine (1-1.5 mg/kg IV) - First-line agent
- Rocuronium (1.0-1.2 mg/kg IV) if contraindicated
Clinical Considerations:
- Ensure adequate volume resuscitation before RSI if possible
- Have vasopressors prepared and ready to administer
- Consider norepinephrine infusion pre-intubation if persistent hypotension
Scenario 5: Status Epilepticus
Induction Agent:
- Propofol (1-2 mg/kg IV) - Preferred due to anticonvulsant properties
- Ketamine (1-2 mg/kg IV) as alternative, especially if hypotensive
Paralytic Agent:
- Succinylcholine (1-1.5 mg/kg IV) - First-line agent
- Rocuronium (1.0-1.2 mg/kg IV) if contraindicated
Clinical Considerations:
- Continue antiepileptic medications during RSI preparation
- Monitor for propofol-related hypotension
- Consider EEG monitoring post-intubation if available
Important Caveats and Pitfalls
Always administer a sedative-hypnotic induction agent when using a neuromuscular blocking agent to prevent awareness during paralysis 1
Have sugammadex readily available when using rocuronium in case a "cannot intubate, cannot ventilate" scenario develops 1
Adjust dosing based on actual body weight for obese patients, particularly for rocuronium 2
Beware of delayed post-RSI sedation and analgesia with rocuronium compared to succinylcholine, which may increase risk of awareness during paralysis 3
Consider nasogastric tube decompression in patients at high risk for regurgitation before RSI 1
The guidelines strongly emphasize that a sedative-hypnotic agent should always be used when administering a neuromuscular blocking agent for intubation, with no exceptions 1. This is crucial to prevent awareness during paralysis, which can be a traumatic experience for patients.
While there is no definitive evidence showing superiority of one induction agent over another regarding mortality or hemodynamic stability 1, the choice should be guided by the patient's specific clinical condition and the provider's familiarity with the medication.
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