What is the recommended protocol for rapid sequence intubation (RSI)?

Rapid Sequence Intubation Protocol

Core Medication Regimen

For critically ill adults requiring RSI, administer a sedative-hypnotic agent (etomidate 0.3 mg/kg IV or ketamine 1-2 mg/kg IV) immediately followed by a neuromuscular blocking agent (succinylcholine 1-1.5 mg/kg IV or rocuronium 0.9-1.2 mg/kg IV), with the sedative ALWAYS given first to prevent awareness during paralysis. 1, 2

Induction Agent Selection

• Etomidate 0.3 mg/kg IV is preferred for hemodynamically unstable patients due to minimal blood pressure effects 2, 3
• Ketamine 1-2 mg/kg IV is an appropriate alternative, particularly in pediatric septic shock 2
• The Society of Critical Care Medicine found no significant mortality or hypotension difference between etomidate and other induction agents (ketamine, midazolam, propofol) 1, 4

Neuromuscular Blocking Agent Selection

• Succinylcholine 1-1.5 mg/kg IV is first-line when no contraindications exist (hyperkalemia risk, burns >24 hours, crush injuries, neuromuscular disease) 1, 2
• Rocuronium 0.9-1.2 mg/kg IV is the alternative when succinylcholine is contraindicated 1, 5
• Both agents provide similar first-pass success rates; a French RCT of 1,248 patients showed 74.6% success with rocuronium versus 79.4% with succinylcholine (difference not clinically significant) 1
• Critical consideration for traumatic brain injury: Rocuronium may be safer than succinylcholine, as succinylcholine can transiently increase intracranial pressure and carries hyperkalemia risk 3

Preparation Steps

Positioning

• Use semi-Fowler position (head and torso inclined 20-30 degrees) to reduce aspiration risk and improve first-pass success 2, 4, 3

Preoxygenation Strategy (3-5 minutes)

• Standard patients: 100% oxygen via face mask with oxygen flow >10 L/min, targeting FetO2 >0.9 2, 6
• Severe hypoxemia (PaO2/FiO2 <150): Use noninvasive positive pressure ventilation (NIPPV) 2, 4
• Anticipated difficult airway: Use high-flow nasal oxygen (HFNO) 2, 4
• Agitated/combative patients: Consider medication-assisted preoxygenation (delayed sequence intubation) with ketamine, which increases oxygen saturation by approximately 8.9% 4

Gastric Decompression

• Place nasogastric tube in patients at high risk for regurgitation of gastric contents when benefit outweighs risk 2, 4

Critical Sequencing Algorithm

The medication administration sequence is non-negotiable:

1. Complete preoxygenation (3-5 minutes) 2, 6
2. Administer sedative-hypnotic agent (etomidate or ketamine) 1, 2
3. Immediately follow with neuromuscular blocking agent (within seconds) 1, 2
4. Perform laryngoscopy and intubation when conditions optimal (typically 45-60 seconds after NMBA) 5
5. Confirm tube placement
6. Immediately initiate continuous sedation and analgesia to prevent awareness 2

Dosing for Rapid Sequence Intubation

• Rocuronium for RSI: 0.6-1.2 mg/kg IV provides excellent intubating conditions in <2 minutes 5
• Succinylcholine for RSI: 1-1.5 mg/kg IV 2, 3
• Higher rocuronium doses (1.0-1.2 mg/kg) provide onset times comparable to succinylcholine 5, 7

Post-Intubation Management

• Apply PEEP of at least 5 cmH2O immediately after intubation in hypoxemic patients 2, 4
• Consider recruitment maneuver to improve oxygenation 2, 4
• Initiate continuous sedation and analgesia immediately to prevent awareness 2, 3
• Have vasopressors immediately available, as transient hypotension can occur even with hemodynamically stable agents 3

Critical Pitfalls and Solutions

Administering NMBA Before Sedative

• Risk: Awareness during paralysis occurs in approximately 2.6% of ED intubations when sedation is inadequate 3
• Solution: Always administer sedative-hypnotic first, then immediately follow with NMBA 1, 2

Inadequate Preoxygenation

• Risk: Rapid desaturation during apnea 2, 4
• Solution: Use semi-Fowler positioning, ensure 3-5 minutes of preoxygenation with appropriate device selection based on patient condition 2, 4

Using Succinylcholine in Contraindicated Patients

• Risk: Life-threatening hyperkalemia in patients with burns >24 hours, crush injuries, prolonged immobilization, or neuromuscular disease 2, 3
• Solution: Screen for contraindications; use rocuronium 1.0-1.2 mg/kg when succinylcholine is contraindicated 1, 2

Delayed Post-Intubation Sedation with Rocuronium

• Risk: Rocuronium's longer duration (30-60 minutes) may mask inadequate sedation, as patient cannot move to signal distress 1, 3
• Solution: Implement protocolized post-intubation sedation immediately after tube confirmation; consider clinical pharmacist involvement 3

Medication Errors

• Risk: Accidental administration of neuromuscular blocking agents can be fatal 5
• Solution: Store rocuronium with cap and ferrule intact in a manner that minimizes wrong product selection 5

Special Population: Traumatic Brain Injury

• Preferred regimen: Etomidate 0.3 mg/kg + rocuronium 0.9-1.2 mg/kg 3
• Rationale: Etomidate maintains cerebral perfusion pressure; rocuronium avoids succinylcholine's transient ICP increase 3
• Very low quality evidence suggests increased mortality with succinylcholine in high-severity TBI (OR 4.1; 95% CI 1.2-14.1) 1

Equipment and Personnel Requirements

• RSI should only be performed when facilities for intubation, mechanical ventilation, oxygen therapy, and antagonist (sugammadex for rocuronium) are immediately available 5
• Must be administered by experienced clinicians or adequately trained individuals supervised by an experienced clinician 5
• Use peripheral nerve stimulator to monitor neuromuscular blockade when administering maintenance doses 5