What are the recommended RSI medications for various critical conditions?

Recommended RSI Medications for Various Critical Conditions

For rapid sequence intubation (RSI) in critically ill patients, the choice of medications should be tailored to the specific clinical condition, with ketamine, etomidate, and propofol being the primary hypnotic agents of choice, and succinylcholine or rocuronium as the preferred neuromuscular blocking agents. 1

Scenario 1: Traumatic Brain Injury (TBI) with Hemodynamic Stability

Induction Agent

• First choice: Etomidate 0.3 mg/kg IV
  • Provides hemodynamic stability
  • Minimal effect on intracranial pressure
  • Rapid onset (30-60 seconds)

Neuromuscular Blocking Agent

• First choice: Succinylcholine 1.5 mg/kg IV
  • Fastest onset (45-60 seconds)
  • Short duration (5-10 minutes)
• Alternative (if contraindicated): Rocuronium 1.0-1.2 mg/kg IV
  • Have sugammadex readily available for reversal if needed 1

Adjuncts

• Lidocaine 1-2 mg/kg IV (30 seconds to 5 minutes before intubation) to blunt ICP response 1
• Consider fentanyl 1-3 μg/kg for additional ICP protection

Scenario 2: Shock/Hemodynamic Instability

Induction Agent

• First choice: Ketamine 1-2 mg/kg IV
  • Maintains or increases blood pressure through sympathomimetic effects
  • Preserves respiratory drive
  • Caution: may cause hypotension in catecholamine-depleted patients 1

Neuromuscular Blocking Agent

• First choice: Rocuronium 1.0-1.2 mg/kg IV
  • Avoids succinylcholine's potential for hyperkalemia in critically ill patients
  • Have sugammadex available for reversal if needed

Adjuncts

• Consider vasopressor infusion pre-intubation if systolic BP <90 mmHg
• Fluid bolus 20 mL/kg if hypovolemic 1

Scenario 3: Status Asthmaticus/Severe Bronchospasm

Induction Agent

• First choice: Ketamine 1-2 mg/kg IV
  • Bronchodilatory properties
  • Maintains respiratory drive
  • Preserves hemodynamics

Neuromuscular Blocking Agent

• First choice: Succinylcholine 1.5 mg/kg IV
  • Rapid onset allows quick control of airway
• Alternative: Rocuronium 1.0-1.2 mg/kg IV if contraindication to succinylcholine

Adjuncts

• Consider magnesium sulfate 25-50 mg/kg IV (maximum 2g) over 15-30 minutes for bronchodilation 1
• Continuous albuterol nebulization before and after intubation

Scenario 4: Status Epilepticus

Induction Agent

• First choice: Midazolam 0.2-0.4 mg/kg IV
  • Anticonvulsant properties
  • Synergistic with other anticonvulsants

Neuromuscular Blocking Agent

• First choice: Rocuronium 1.0-1.2 mg/kg IV
  • Longer duration allows continued airway protection during seizure management
  • Avoids succinylcholine's potential to increase intracranial pressure

Adjuncts

• Consider additional anticonvulsants (levetiracetam, phenytoin, or valproate)
• Monitor for respiratory depression, especially with benzodiazepines 1

Scenario 5: Septic Shock

Induction Agent

• First choice: Ketamine 1-1.5 mg/kg IV
  • Maintains hemodynamic stability through sympathomimetic effects
  • Recent evidence suggests no difference in mortality between ketamine and etomidate 1

Neuromuscular Blocking Agent

• First choice: Rocuronium 1.0-1.2 mg/kg IV
  • Avoids potential hyperkalemia with succinylcholine in acidotic patients

Adjuncts

• Pre-intubation fluid bolus if hypovolemic
• Consider vasopressor infusion before induction if persistent hypotension
• Norepinephrine 0.1-1.0 μg/kg/min titrated to effect 1

Important Considerations for All RSI Scenarios

1. Pre-oxygenation: Use non-invasive ventilation or high-flow nasal oxygen for pre-oxygenation in hypoxemic patients 1

2. Positioning: Optimize patient position (head-elevated position if not contraindicated)

3. Gastric Decompression: Consider nasogastric tube decompression before RSI in patients at high risk for aspiration 1

4. Cricoid Pressure: Apply cricoid pressure (10 N awake, 30 N after loss of consciousness) unless contraindicated 1

5. Post-intubation Management:

   • Apply PEEP of at least 5 cmH2O after intubation in hypoxemic patients
   • Consider recruitment maneuver post-intubation 1
   • Confirm tube placement with waveform capnography

Common Pitfalls to Avoid

1. Underdosing NMBAs: Inadequate dosing leads to poor intubating conditions and increased complications. Use full RSI doses of rocuronium (1.0-1.2 mg/kg) when succinylcholine is contraindicated 1

2. Ignoring hemodynamics: Failure to anticipate and prepare for post-induction hypotension. Have vasopressors prepared before induction in unstable patients.

3. Inadequate pre-oxygenation: Ensure 3-5 minutes of adequate pre-oxygenation or 8 vital capacity breaths when time permits.

4. Delayed sequence intubation: Consider ketamine (1-1.5 mg/kg) to facilitate pre-oxygenation in agitated patients who cannot tolerate conventional pre-oxygenation 1

5. Multiple intubation attempts: Limit attempts to three before moving to an alternative airway management strategy 1

The most recent and highest quality evidence supports using a protocol-based approach to RSI that includes both respiratory and cardiovascular components to minimize complications in critically ill patients 1.