What are the recommended drugs for intubation in a typical adult patient in the Emergency Room (ER) setting?

Recommended Drugs for Intubation in the Emergency Room Setting

For rapid sequence intubation in the ER, administer a sedative-hypnotic induction agent (ketamine 1-2 mg/kg, etomidate 0.2-0.4 mg/kg, or propofol 2 mg/kg) immediately followed by a neuromuscular blocking agent (succinylcholine 1-1.5 mg/kg or rocuronium 0.9-1.2 mg/kg), with ketamine preferred in most circumstances due to its hemodynamic stability. 1, 2

Core Medication Protocol

Sedative-Hypnotic Induction Agents (Choose One)

A sedative-hypnotic agent must always be administered when using a neuromuscular blocking agent to prevent awareness during paralysis. 1, 2

• Ketamine (1-2 mg/kg IV) is increasingly favored as the first-line induction agent due to its sympathomimetic properties that maintain hemodynamic stability, making it particularly valuable in hemodynamically unstable patients 2, 3

  • Preserves respiratory drive and has quick onset with short duration of action 3
  • Some retrospective evidence suggests ketamine may produce slightly higher hypotension rates (18.3% vs 12.4%) compared to etomidate in shock/sepsis patients, though this remains controversial 2, 4

• Etomidate (0.2-0.4 mg/kg IV) provides relatively stable hemodynamics and may produce less hypotension than ketamine in patients with shock or sepsis based on retrospective evidence 2, 4

  • The Society of Critical Care Medicine guidelines suggest no significant difference between etomidate and other induction agents with respect to mortality or hypotension (conditional recommendation, moderate quality evidence) 1
  • Corticosteroids should not be administered following RSI with etomidate for the purpose of counteracting etomidate-induced adrenal suppression 1

• Propofol (2 mg/kg IV) suppresses airway reflexes more effectively than other agents but causes vasodilation and hypotension, requiring caution in unstable patients 2

  • Should be used with extreme caution in hemodynamically unstable patients 5

Neuromuscular Blocking Agents (Choose One)

The Society of Critical Care Medicine strongly recommends administering an NMBA when a sedative-hypnotic induction agent is used for intubation. 1, 2

• Succinylcholine (1-1.5 mg/kg IV) is the first-line neuromuscular blocking agent for RSI when no contraindications exist 1, 2, 3

  • Provides rapid onset with median 1 minute to intubating conditions 1, 2
  • Shorter duration of action facilitates more rapid provision of post-intubation analgosedation 1
  • Contraindications include: hyperkalemia, burns >24 hours old, crush injuries, denervation injuries, prolonged immobilization, malignant hyperthermia history 2
  • One observational study showed potential increased mortality in severe traumatic brain injury patients, though this requires further validation 1

• Rocuronium (0.9-1.2 mg/kg IV) should be used when succinylcholine is contraindicated 1, 2, 3

  • High-dose rocuronium (0.9-1.2 mg/kg) provides onset in less than 2 minutes, comparable to succinylcholine 2, 6
  • Longer duration of action (58-67 minutes at high doses) may delay provision of post-intubation analgosedation, potentially increasing risk of patient awareness 1, 6
  • Sugammadex must be immediately available when rocuronium is used to reverse neuromuscular blockade in "cannot intubate/cannot oxygenate" scenarios 2
  • Dose according to actual body weight, not ideal body weight 6

Evidence Comparing Neuromuscular Blocking Agents

The Society of Critical Care Medicine suggests administering either rocuronium or succinylcholine for RSI when there are no known contraindications to succinylcholine (conditional recommendation, low quality evidence) 1

• A large RCT of 1,248 patients found first-pass success rates of 74.6% with rocuronium (1.2 mg/kg) versus 79.4% with succinylcholine (1 mg/kg), with results inconclusive based on a noninferiority margin of 7% 1
• An ICU-based RCT of 401 patients showed similar first-pass success: 82% with rocuronium versus 84% with succinylcholine 1
• Most studies reported that post-intubation analgosedation was provided more rapidly when succinylcholine was used, as the longer duration of rocuronium may prevent patient movement that serves as a cue for staff to provide sedation 1

Medication Administration Sequence

Administer the sedative-hypnotic agent before or simultaneously with the NMBA—never paralyze without sedation. 2, 3

• Failure to provide adequate sedation before paralysis results in awareness during paralysis in approximately 2.6% of emergency department intubations 2
• Recent evidence suggests administering the neuromuscular blocking agent first may result in modestly faster time to intubation (6 seconds reduction), though both orders are acceptable 7

Adjunctive Medications

• Co-induction with rapidly-acting opioids (fentanyl 100-150 mcg or sufentanil 10-15 mcg) enables lower hypnotic doses, promoting cardiovascular stability and minimizing intracranial pressure changes 2

Special Populations and Considerations

Agitated/Uncooperative Patients

• Medication-assisted preoxygenation (delayed sequence intubation) is recommended for agitated, delirious, or combative patients who cannot tolerate preoxygenation devices 1, 5, 2
• Administer ketamine (1-1.5 mg/kg IV) to achieve dissociative state, allow 3 minutes of preoxygenation, then proceed with NMBA 5, 2
• Studies show mean oxygen saturation increase of 8.9% after ketamine administration for preoxygenation 5

Hemodynamically Unstable Patients

• Ketamine is preferred due to sympathomimetic properties 2, 3
• Include a cardiovascular protocol component defining conditions for fluid challenge and early catecholamine administration 2
• All sedatives can cause vasodilation, hypotension, and bradycardia by abolishing sympathetic tone 5

Severely Hypoxemic Patients (PaO2/FiO2 < 150)

• Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 1, 5, 2
• Consider high-flow nasal oxygen when difficult laryngoscopy is anticipated 1, 5, 2

Obstetric Patients (Cesarean Section)

• Rocuronium is NOT recommended for rapid sequence induction in Cesarean section patients, as it results in poor or inadequate intubating conditions when lower doses of thiopental are used 5, 6

Critical Pitfalls and How to Avoid Them

• Never administer NMBA without sedation first: This causes awareness during paralysis, occurring in 2.6% of ED intubations 2
• Inadequate preoxygenation: Ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 5, 2
• Delayed post-intubation analgosedation with rocuronium: The longer duration may prevent patient movement cues; implement protocolized care and consider clinical pharmacist involvement 1
• Succinylcholine in contraindicated patients: Screen for hyperkalemia risk factors, burns >24 hours, crush injuries, denervation, prolonged immobilization, malignant hyperthermia history 2
• Failure to have sugammadex available when using rocuronium: This is essential for reversal in cannot intubate/cannot oxygenate scenarios 2

Post-Intubation Management

• Apply recruitment maneuver and PEEP ≥5 cmH₂O after intubation in hypoxemic patients 5, 2
• Confirm tube placement with waveform capnography 2
• Provide immediate post-intubation analgosedation, particularly when rocuronium is used 1