Recommended Medication Dosages for Rapid Sequence Intubation (RSI)
For rapid sequence intubation, administer a sedative-hypnotic agent followed by a neuromuscular blocking agent, with appropriate pretreatment medications when indicated. 1
Pretreatment Medications
- Atropine: 0.01-0.02 mg/kg IV (maximum: 0.5 mg) for children aged 28 days to 8 years, particularly with septic shock, hypovolemia, or when succinylcholine is used 1
- Lidocaine: 1-2 mg/kg IV as a single dose 30 seconds to 5 minutes before airway instrumentation for patients with increased intracranial pressure 1
Sedative-Hypnotic Agents
Pediatric Patients
- Ketamine: 1-2 mg/kg IV (first-line for hemodynamically unstable patients) 1
- Etomidate: 0.2-0.4 mg/kg IV (maximum: 20 mg) (preferred for patients with head injury) 2, 1
- Diazepam: 0.2-0.4 mg/kg IV/IO (maximum: 20 mg) 3
Adult Patients
- Etomidate: 0.2-0.4 mg/kg IV 2, 4
- Ketamine: 1-2 mg/kg IV (alternative for hemodynamically unstable patients) 4
- Propofol: 1-2 mg/kg IV (caution in hemodynamically unstable patients) 5
Neuromuscular Blocking Agents
Depolarizing Agent
- Succinylcholine: 1, 5
- Adults: 1-1.5 mg/kg IV
- Children >10 years: 1-1.5 mg/kg IV
- Children 1-10 years: 1.2 mg/kg IV
- Infants 1 month to 1 year: 2.0 mg/kg IV
- Neonates <1 month: 1.8 mg/kg IV
Non-depolarizing Agent
- Rocuronium: 1, 6
- Standard dose: 0.6 mg/kg IV
- Rapid sequence intubation: 0.9-1.2 mg/kg IV
- Onset time: 1-2 minutes (dose-dependent)
- Duration: 45-70 minutes
Special Considerations
Increased Intracranial Pressure
- Etomidate is preferred (0.2-0.4 mg/kg IV) as it lowers ICP and maintains hemodynamic stability 1
- Consider adding lidocaine 1-2 mg/kg IV 1
- Mannitol: 0.25-1 g/kg IV given over 20-30 minutes (0.5 g/kg over 15 minutes for acute intracranial hypertensive crisis) 2
Hemodynamically Unstable Patients
- Ketamine is preferred (1-2 mg/kg IV) due to its sympathomimetic effects 1, 4
- Avoid propofol due to risk of hypotension 5
Status Epilepticus
- Lorazepam: 0.05-0.10 mg/kg IV/IM (maximum: 4 mg per dose), may repeat every 10-15 minutes if needed 2
- Midazolam: 0.2 mg/kg IM (maximum: 6 mg per dose); may repeat every 10-15 minutes 2
Common Pitfalls and Safety Considerations
- Failure to administer atropine in young children when using succinylcholine increases risk of clinically significant bradycardia 1
- Using succinylcholine in patients with contraindications (hyperkalemia, burns, crush injuries, neuromuscular disorders) can lead to cardiac arrest 1, 7
- Not having sugammadex available when using high-dose rocuronium for potential reversal in "can't intubate, can't ventilate" scenarios 1
- Inadequate sedation post-RSI, especially when using non-depolarizing paralytics 7
- Using etomidate in septic patients without considering potential adrenal suppression (though evidence suggests this may not significantly impact outcomes) 2, 7
Medication Reversal Agents
- Flumazenil (for benzodiazepine reversal): 0.01-0.02 mg/kg IV (maximum: 0.2 mg); can repeat at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower 3
- Sugammadex (for rocuronium reversal): Should be rapidly available when rocuronium is used 1
Remember that medication selection should be based on the patient's clinical condition, with careful consideration of hemodynamic status, intracranial pressure concerns, and potential contraindications to specific agents.