What are the recommended medications for rapid intubation in a patient with a suspected drug overdose?

Rapid Sequence Intubation Medications for Drug Overdose

For drug overdose patients requiring intubation, use etomidate (0.2-0.3 mg/kg) or ketamine (1-2 mg/kg) as the induction agent, followed immediately by either succinylcholine (1-1.5 mg/kg) or rocuronium (0.9-1.2 mg/kg) as the neuromuscular blocking agent, with the specific choice guided by hemodynamic stability and contraindications. 1, 2, 3

Patient Assessment and Preparation

Before medication administration, rapidly assess:

• Hemodynamic status: Overdose patients frequently present with sympathetic exhaustion and occult hypovolemia that becomes unmasked after induction 4
• Aspiration risk: All overdose patients should be considered "full stomach" and managed with RSI technique 1, 5
• Cooperation level: Agitated or combative patients require medication-assisted preoxygenation before paralysis 2, 3

Position the patient in semi-Fowler position (head and torso inclined) to reduce aspiration risk and improve first-pass success 1, 2, 5

Preoxygenation Strategy

• For cooperative patients: Use high-flow nasal oxygen (HFNO) or noninvasive positive pressure ventilation (NIPPV) for 3-5 minutes 1, 2
• For agitated/combative patients: Administer ketamine 1-1.5 mg/kg IV for medication-assisted preoxygenation (delayed sequence intubation), which increases oxygen saturation by approximately 8.9% before administering the neuromuscular blocker 2, 3

Induction Agent Selection

Etomidate (Preferred for Hemodynamically Unstable Patients)

Dose: 0.2-0.3 mg/kg IV 1, 3

• Provides minimal cardiovascular depression, making it ideal for overdose patients with sympathetic exhaustion 1, 3
• Recent high-quality evidence shows no difference in mortality or hypotension compared to other agents 1
• Rapid onset with short duration of action 3

Ketamine (Alternative, Especially for Agitated Patients)

Dose: 1-2 mg/kg IV 1, 3

• Maintains respiratory drive and increases catecholamine release 3
• Critical caveat: May cause paradoxical hypotension in critically ill overdose patients with depleted catecholamine stores 1, 3
• Preferred for medication-assisted preoxygenation in uncooperative patients 2, 3

Avoid or Use with Extreme Caution

• Propofol: Causes significant vasodilation and hypotension, particularly problematic in overdose patients 1, 4
• Midazolam: Longer onset of action and potent venodilation at RSI doses 1

Neuromuscular Blocking Agent Selection

A neuromuscular blocking agent must always be administered when a sedative-hypnotic is used for intubation 1, 3

Succinylcholine (First-Line Choice)

Dose: 1-1.5 mg/kg IV 1, 2, 6

• Rapid onset (30-60 seconds) with short duration (5-10 minutes) 1, 7
• Allows faster return of spontaneous ventilation if intubation fails 1
• Contraindications: Hyperkalemia, malignant hyperthermia history, neuromuscular disease, significant burns >24 hours old 7

Rocuronium (Alternative When Succinylcholine Contraindicated)

Dose: 0.9-1.2 mg/kg IV for RSI 1, 2, 6

• Provides intubating conditions in approximately 1 minute at high doses 6
• Duration of 58-67 minutes at RSI doses 6
• Critical requirement: Sugammadex must be immediately available for reversal in "cannot intubate/cannot oxygenate" scenarios 1, 3, 5
• Important pitfall: Longer duration may delay post-intubation analgosedation, potentially increasing awareness risk 1, 5

Evidence-Based Medication Algorithm

For hemodynamically stable overdose patients:

• Etomidate 0.2-0.3 mg/kg + Succinylcholine 1-1.5 mg/kg 1, 3

For hemodynamically unstable overdose patients:

• Etomidate 0.2-0.3 mg/kg (preferred) + Succinylcholine 1-1.5 mg/kg 1, 3

For agitated/uncooperative overdose patients:

• Ketamine 1-1.5 mg/kg for preoxygenation, then after 3 minutes: Etomidate 0.2-0.3 mg/kg + Succinylcholine 1-1.5 mg/kg 2, 3

When succinylcholine is contraindicated:

• Etomidate 0.2-0.3 mg/kg + Rocuronium 0.9-1.2 mg/kg (with sugammadex immediately available) 1, 3, 6

Critical Timing and Administration

• Administer medications in rapid succession without delay 3, 5
• Perform immediate endotracheal tube placement before assisted ventilation begins 3, 5
• Do not administer additional doses of succinylcholine if initial intubation fails—proceed to rescue airway plan 1

Overdose-Specific Considerations

Recent evidence demonstrates that overdose patients have higher first-pass success without adverse events (85.0%) compared to other indications (78.7%), with significantly less hypotension (1.5% vs 4.1%) 8. However, this favorable profile depends on appropriate medication selection and technique.

Key risk factors for intubation in overdose patients include younger age and obstructive lung disease 9. Patients with obstructive lung disease have significantly more hypercapnia and acidemia, requiring particular attention to preoxygenation 9.

Common Pitfalls and How to Avoid Them

• Inadequate preoxygenation in agitated patients: Use ketamine-based medication-assisted preoxygenation rather than attempting to force mask on combative patient 2, 3
• Postintubation hypotension: Anticipate marked attenuation of sympathetic tone after resolving hypoxia/hypercarbia; have vasopressors immediately available 4
• Failure to have sugammadex available when using rocuronium: This is mandatory for safe practice 1, 3, 5
• Using propofol in hemodynamically unstable overdose patients: Choose etomidate instead 1, 3
• Forgetting that all analgesics and sedatives can cause vasodilation and hypotension by abolishing sympathetic tone: Reduce standard doses and titrate to effect 2, 4