What is the agent used for rapid sequence intubation (RSI)?

From the Guidelines

For rapid sequence intubation (RSI), the recommended agents include a sedative followed by a neuromuscular blocking agent, with etomidate (0.3 mg/kg IV) or ketamine (1-2 mg/kg IV) as the sedative, and succinylcholine (1-1.5 mg/kg IV) or rocuronium (1-1.2 mg/kg IV) as the paralytic agent, as suggested by the most recent guidelines 1.

Sedative Agents

The choice of sedative agent depends on the patient's medical history and clinical situation. Etomidate is a commonly used sedative due to its rapid onset and minimal cardiovascular effects. Ketamine is an alternative, particularly useful in hypotensive patients due to its sympathomimetic properties.

• Etomidate (0.3 mg/kg IV) is a popular choice for RSI due to its rapid onset (30-60 seconds) and short duration, with minimal effects on cardiovascular stability 1.
• Ketamine (1-2 mg/kg IV) is a suitable alternative, especially in patients with hypotension, as it has sympathomimetic properties that can help maintain blood pressure 1.

Paralytic Agents

The choice of paralytic agent depends on the presence of contraindications to succinylcholine. Succinylcholine is the preferred paralytic agent due to its rapid onset and short duration. Rocuronium is an excellent alternative when succinylcholine is contraindicated.

• Succinylcholine (1-1.5 mg/kg IV) is often the preferred paralytic agent due to its rapid onset (45-60 seconds) and short duration (5-10 minutes) 1.
• Rocuronium (1-1.2 mg/kg IV) is an excellent alternative, especially when succinylcholine is contraindicated, such as in patients with hyperkalemia, burns, crush injuries, or neuromuscular disorders 1.

Pre-treatment and Other Considerations

Pre-treatment with lidocaine and fentanyl can help blunt sympathetic response in patients with increased intracranial pressure or cardiovascular disease.

• Pre-treatment with lidocaine (1.5 mg/kg IV) and fentanyl (2-3 mcg/kg IV) 3 minutes before induction can help minimize the risk of aspiration and blunt sympathetic response in patients with increased intracranial pressure or cardiovascular disease 1.

From the FDA Drug Label

Rocuronium bromide injection is a nondepolarizing neuromuscular blocking agent indicated as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation Rapid sequence intubation: 0.6 to 1.2 mg/kg.

The agent used for rapid sequence intubation (RSI) is rocuronium bromide injection, with a recommended dose of 0.6 to 1.2 mg/kg 2.

From the Research

Agents Used for Rapid Sequence Intubation (RSI)

The agents used for RSI include:

• Sedative induction agents such as etomidate and ketamine 3, 4, 5
• Neuromuscular blocking agents (NMBAs) such as succinylcholine and rocuronium 3, 6, 7
• Pretreatment medications including atropine, lidocaine, and fentanyl, although their use has fallen out of favor due to limited evidence for their use outside of select clinical scenarios 3, 6

Characteristics of Agents Used for RSI

• Etomidate has a rapid onset of action, minimal respiratory or cardiovascular effects, and is cerebroprotective, making it an ideal agent for patients with head injuries or hemodynamic instability 4, 5
• Ketamine has a more favorable hemodynamic profile compared to other induction agents, but may produce more hypotension than etomidate in patients presenting with shock or sepsis 3
• Succinylcholine and rocuronium are the preferred NMBAs, with minimal differences in first-pass success rates, and selection between the two is based on patient-specific factors, half-life, and adverse effect profiles 3, 6, 7

Considerations for Medication Use in RSI

• The selection and use of medications for RSI is critical for success, and the optimal selection, dosing, and administration of RSI medications is complicated, requiring further research in several areas 3
• The role of the emergency department pharmacist is integral in the steps of pretreatment, paralysis with induction, and postintubation management, and they should be familiar with the medications involved in RSI to facilitate successful intubation and patient safety 6