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

Recommended Medications for Rapid Sequence Intubation (RSI)

For rapid sequence intubation (RSI), a combination of a sedative-hypnotic agent and a neuromuscular blocking agent (NMBA) should be administered, with etomidate or ketamine as the preferred sedative agents and succinylcholine or rocuronium as the preferred NMBAs. 1

Sedative-Hypnotic Agents

First-Line Options:

1. Etomidate

   • Dosing: 0.2-0.3 mg/kg IV 1
   • Advantages:
     • Favorable hemodynamic profile
     • Quick onset and short duration of action
     • Minimal effect on blood pressure
   • Considerations:
     • May cause adrenal suppression, but evidence suggests no significant impact on mortality or vasopressor requirements 1
     • Avoid in sepsis if possible

2. Ketamine

   • Dosing: 1-2 mg/kg IV 1
   • Advantages:
     • Sympathomimetic properties (may preserve hemodynamics)
     • Preserves respiratory drive
     • Quick onset and short duration
   • Considerations:
     • May cause hypotension in catecholamine-depleted patients 1
     • Increased salivation (consider co-administration of atropine) 1
     • Preferred in hemodynamically unstable patients 1

Alternative Options:

1. Propofol

   • Dosing: Variable based on clinical situation
   • Considerations:
     • Most profound effect on blood pressure - use with caution in critically ill 1
     • Best for elective procedures or hemodynamically stable patients 1

2. Midazolam

   • Considerations:
     • Longer onset of action compared to etomidate and ketamine 1
     • Potent venodilator at RSI doses 1
     • Less desirable for emergency RSI

Neuromuscular Blocking Agents (NMBAs)

First-Line Options:

1. Succinylcholine

   • Dosing: 1.5 mg/kg IV 1, 2
   • Advantages:
     • Rapid onset (60 seconds)
     • Short duration of action
   • Contraindications:
     • Hyperkalemia
     • Malignant hyperthermia risk
     • Neuromuscular disorders
     • Burns or crush injuries >24 hours old

2. Rocuronium

   • Dosing: 0.9-1.2 mg/kg IV 1, 3
     • Higher doses (1.0-1.2 mg/kg) recommended when succinylcholine is contraindicated 1
   • Advantages:
     • Excellent intubating conditions comparable to succinylcholine at higher doses 1, 3
     • No hyperkalemia risk
   • Considerations:
     • Longer duration of action than succinylcholine 1
     • Sugammadex should be available when rocuronium is used 1

Pediatric Considerations

• Sedative agents:

  • Ketamine: 3-4 mg/kg before 18 months of age; 2 mg/kg after 1
  • Etomidate: First choice in children >2 years (except in sepsis) 1

• NMBAs:

  • Succinylcholine: First-line for children with respiratory or cardiovascular compromise 1
  • Rocuronium: 1.0-1.2 mg/kg when succinylcholine is contraindicated 1

RSI Protocol Algorithm

1. Pre-oxygenation

   • 3-5 minutes of high-flow oxygen

2. Pre-treatment medications (if indicated)

   • Atropine: Consider for children to prevent bradycardia
   • Lidocaine: Consider for patients with increased ICP (1-2 mg/kg IV) 1

3. Induction

   • Hemodynamically stable patient: Etomidate 0.2-0.3 mg/kg IV
   • Hemodynamically unstable patient: Ketamine 1-2 mg/kg IV

4. Paralysis (30-60 seconds after induction)

   • No contraindications: Succinylcholine 1.5 mg/kg IV
   • Contraindications to succinylcholine: Rocuronium 1.0-1.2 mg/kg IV

5. Laryngoscopy and intubation

   • Attempt 60-90 seconds after NMBA administration

6. Post-intubation management

   • Confirm tube placement
   • Initiate appropriate sedation/analgesia

Common Pitfalls and Considerations

1. Underdosing of medications

   • Ensure appropriate weight-based dosing
   • For obese patients, dose based on actual body weight 3

2. Failure to anticipate hemodynamic effects

   • Have vasopressors readily available
   • Select induction agent based on hemodynamic status

3. Inappropriate NMBA selection

   • Know contraindications to succinylcholine
   • Have sugammadex available when using rocuronium 1

4. Delayed sequence

   • Administer sedative and NMBA in rapid succession
   • Always administer a sedative when using an NMBA 1

5. Medication shortages

   • Have standardized alternatives identified
   • Consider a standardized protocol to reduce dosing errors 2

The Society of Critical Care Medicine guidelines suggest there is no significant difference between etomidate and other induction agents with respect to mortality or hypotension 1, allowing clinicians to select the most appropriate agent based on the patient's clinical condition and provider familiarity with the medication.