What medications are typically given before emergency intubation in a typical adult patient without specific allergies or contraindications?

Medications for Emergency Intubation

For emergency intubation in a typical adult patient, administer a sedative-hypnotic agent (induction agent) followed immediately by a neuromuscular blocking agent (NMBA) in rapid succession—this is the standard rapid sequence intubation (RSI) approach that optimizes first-pass success and minimizes complications. 1

Core Medication Regimen

Induction Agent (Sedative-Hypnotic)

Ketamine 1-2 mg/kg IV is the preferred induction agent for critically ill patients because it maintains cardiovascular stability better than other agents, particularly when there is increased risk of hemodynamic instability. 1 This is especially important in emergency settings where patients may be hypovolemic, septic, or otherwise hemodynamically compromised.

Alternative induction agents include:

• Etomidate 10-20 mg (or 0.3 mg/kg) can be used if ketamine is contraindicated, though it suppresses adrenal function and its use in septic shock remains controversial. 1, 2
• Propofol 2-2.5 mg/kg may be used if hemodynamics allow, but causes more hypotension than ketamine or etomidate. 1, 3
• Midazolam 2-5 mg can be combined with etomidate or propofol for additional sedation. 1

Neuromuscular Blocking Agent (Paralytic)

Either rocuronium 1.2 mg/kg IV or succinylcholine 1.5 mg/kg IV should be administered immediately after loss of consciousness. 1 The 2023 Society of Critical Care Medicine guidelines suggest either agent is acceptable when there are no contraindications to succinylcholine. 1

Rocuronium advantages:

• No risk of hyperkalemia, malignant hyperthermia, or masseter spasm 1
• Safer in patients with burns, crush injuries, denervation injuries, or prolonged immobilization 1
• Duration of action is 30-60 minutes, which can be reversed with sugammadex if needed 1, 4

Succinylcholine advantages:

• Slightly faster onset (muscle fasciculation complete in ~45-60 seconds) 1, 5
• Shorter duration of action (4-6 minutes), allowing faster return of spontaneous breathing if intubation fails 5

Critical dosing detail: Rocuronium must be dosed at 1.2 mg/kg (not the standard 0.6 mg/kg) for RSI to achieve onset times comparable to succinylcholine. 1, 4 At 0.6 mg/kg, rocuronium takes significantly longer to achieve optimal intubating conditions. 4

Adjunctive Medications

Opioid Analgesics

Fentanyl 100-150 mcg or sufentanil 10-15 mcg IV should be administered to suppress laryngeal reflexes and provide optimal intubating conditions while blunting the hemodynamic response to laryngoscopy. 1 This is particularly important for patients with head injury or cardiovascular disease.

Lidocaine

Intravenous lidocaine 1.5 mg/kg (approximately 100 mg for average adult) can be given 2-3 minutes before induction to blunt increases in intracranial pressure during laryngoscopy, though evidence for routine use is mixed. 1, 6 This is most relevant for patients with known or suspected elevated ICP.

Vasopressors

Have vasopressors immediately available (epinephrine for bolus or norepinephrine infusion) as hypotension is common during RSI in critically ill patients. 1, 7 Do not wait for hypotension to develop—prepare these medications before beginning the procedure.

Critical Timing and Sequence

1. Pre-oxygenate with high-flow oxygen via well-fitting mask for 3-5 minutes to maximize safe apnea time. 1

2. Administer fentanyl/sufentanil first (if using), at least 2-3 minutes before induction to allow time for effect. 1

3. Administer induction agent (ketamine, etomidate, or propofol) and wait for loss of consciousness. 1

4. Immediately administer NMBA (rocuronium or succinylcholine) as soon as consciousness is lost. 1

5. Wait for full neuromuscular blockade before attempting laryngoscopy—this takes approximately 45-60 seconds for succinylcholine or 60 seconds for rocuronium 1.2 mg/kg. 1, 7

Common Pitfalls to Avoid

Do not administer paralyzing agents without sedation—this causes awareness under paralysis, which is a devastating complication. 8, 6 Eight patients in one trauma series received paralytics alone without any sedative or analgesic, which is never acceptable. 6

Do not use inadequate doses of rocuronium—the standard intubating dose of 0.6 mg/kg is insufficient for RSI and will result in suboptimal intubating conditions and delayed onset. 1, 4 For RSI, rocuronium must be dosed at 1.2 mg/kg. 1

Do not attempt laryngoscopy before full paralysis is achieved—premature laryngoscopy causes coughing, laryngospasm, and increased ICP, and significantly worsens intubating conditions. 1, 7 Use a peripheral nerve stimulator or wait the full 60 seconds after NMBA administration. 1

Ensure adequate post-intubation sedation and analgesia—patients who receive rocuronium are at higher risk of being awake under paralysis because of its longer duration of action (30-60 minutes vs 4-6 minutes for succinylcholine). 8 Immediately initiate continuous sedation (propofol 30-50 mcg/kg/min or midazolam infusion) and analgesia (fentanyl 0.5-1 mcg/kg/hr) after successful intubation. 8

Have sugammadex immediately available when using rocuronium in case of "cannot intubate, cannot ventilate" scenario—sugammadex 16 mg/kg rapidly reverses rocuronium-induced paralysis. 1