What are the recommended drugs and dosages for rapid sequence intubation (RSI)?

Rapid Sequence Intubation Drug Regimen

For rapid sequence intubation in critically ill adults, administer a sedative-hypnotic agent (etomidate 0.3 mg/kg IV or ketamine 1-2 mg/kg IV) followed immediately by a neuromuscular blocking agent (succinylcholine 1-1.5 mg/kg IV or rocuronium 0.9-1.2 mg/kg IV). 1, 2

Critical Sequencing Rule

The sedative-hypnotic agent MUST be administered before the neuromuscular blocking agent to prevent awareness during paralysis. 1, 2 Failure to provide adequate sedation before paralysis results in awareness in approximately 2.6% of emergency department intubations. 3

Induction Agent Selection

First-Line: Etomidate

• Etomidate (0.3 mg/kg IV) is the preferred induction agent for hemodynamically unstable patients due to its superior hemodynamic stability. 1, 2
• The Society of Critical Care Medicine confirms etomidate provides the most favorable hemodynamic profile with no mortality difference compared to other agents. 4, 2
• Etomidate demonstrates lower rates of peri-intubation hypotension compared to ketamine (12.4% vs 18.3%, OR 1.4). 2
• Despite causing transient adrenal suppression, corticosteroid administration following etomidate is NOT recommended, as multiple RCTs showed no mortality benefit. 4, 1

Alternative: Ketamine

• Ketamine (1-2 mg/kg IV) serves as an alternative when etomidate is contraindicated or unavailable. 1, 2
• Use the lower end of the dosing range (1 mg/kg) in hemodynamically compromised patients to minimize cardiovascular effects while maintaining adequate sedation. 1
• Critical caveat: In critically ill patients with depleted catecholamine stores, ketamine may cause paradoxical hypotension despite its sympathomimetic properties. 1, 2

Neuromuscular Blocking Agent Selection

First-Line: Succinylcholine

• Succinylcholine (1-1.5 mg/kg IV) is the first-line neuromuscular blocking agent when no contraindications exist. 1, 2
• Provides rapid onset with excellent intubating conditions in most patients within 60-90 seconds. 5

Alternative: Rocuronium

• Rocuronium (0.9-1.2 mg/kg IV) should be used when succinylcholine is contraindicated. 1, 2
• The FDA label confirms that doses of 0.6-1.2 mg/kg provide excellent or good intubating conditions in most patients within 2 minutes. 5
• Higher doses (≥0.9 mg/kg) are required for optimal rapid sequence conditions comparable to succinylcholine. 1, 5
• Sugammadex must be immediately available when using high-dose rocuronium for reversal in "cannot intubate, cannot ventilate" scenarios. 1, 2
• Wait at least 60 seconds after rocuronium administration before attempting intubation. 1

Timing and Administration

• Neuromuscular block sufficient for intubation (80% block or greater) is attained in a median time of 1 minute with rocuronium 0.6 mg/kg, and most patients have intubation completed within 2 minutes. 5
• Maximum blockade with rocuronium is achieved in most patients in less than 3 minutes. 5
• Ensure full neuromuscular blockade before attempting intubation to prevent coughing or movement that increases aspiration risk. 1, 2

Common Pitfalls and How to Avoid Them

• Never administer the neuromuscular blocking agent before the sedative-hypnotic agent, as this causes awareness during paralysis. 1, 2, 3
• Have vasopressors immediately available for managing potential hypotension during RSI, particularly with ketamine in critically ill patients. 1
• In obese patients, dose rocuronium based on actual body weight, not ideal body weight, as dosing by ideal body weight results in longer time to maximum block and inadequate intubating conditions. 5
• Do not use rocuronium for rapid sequence intubation in Cesarean section patients, as the FDA label specifically states it is not recommended for this indication due to inadequate intubating conditions in some patients. 5