Should Rapid Sequence Intubation (RSI) medications be used during Cardiopulmonary Resuscitation (CPR) intubation in adult patients with cardiac arrest or severe respiratory distress?

RSI Medications During CPR Intubation

Do not use standard RSI medications (sedative-hypnotics and neuromuscular blocking agents) during active cardiac arrest/CPR, as these patients are already unconscious and lack protective airway reflexes—proceed directly to intubation without pharmacologic agents. 1, 2

Critical Distinction: Cardiac Arrest vs. Peri-Arrest States

The question requires clarification between two distinct clinical scenarios:

During Active Cardiac Arrest (Pulseless)

• Omit all RSI medications entirely - patients in cardiac arrest are unconscious and unresponsive, making sedative-hypnotics and neuromuscular blocking agents unnecessary and potentially harmful by delaying definitive airway management 1, 2
• Proceed directly to laryngoscopy and intubation without pharmacologic facilitation 1
• Focus on high-quality chest compressions with minimal interruption for intubation attempts 1

In Peri-Arrest States (Severe Respiratory Distress with Pulse)

• Use full RSI protocol with both sedative-hypnotic and neuromuscular blocking agents when the patient has a pulse but is in extremis 1, 2, 3
• The Society of Critical Care Medicine strongly recommends administering an NMBA when a sedative-hypnotic induction agent is used for intubation (strong recommendation, low quality evidence) 1, 2

RSI Protocol for Peri-Arrest Patients (With Pulse)

Positioning and Preoxygenation

• Use semi-Fowler position (head and torso inclined) to reduce aspiration risk and improve first-pass success 2, 3
• For severe hypoxemia (PaO2/FiO2 < 150), use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 2
• When difficult laryngoscopy is anticipated, use high-flow nasal oxygen (HFNO) 2
• For agitated or combative patients, use medication-assisted preoxygenation with ketamine (1-1.5 mg/kg IV) to achieve dissociative state, followed by 3 minutes of preoxygenation before administering the NMBA 1, 2

Medication Selection Algorithm

For Hemodynamically Unstable Patients (Shock, Hypotension):

• Induction agent: Etomidate 0.2-0.3 mg/kg IV (preferred due to minimal cardiovascular depression) 2, 4
• Alternative: Ketamine 1-2 mg/kg IV, though recent retrospective evidence suggests etomidate produces less hypotension than ketamine in shock/sepsis 5
• Neuromuscular blocker: Succinylcholine 1-1.5 mg/kg IV (preferred for rapid onset and short duration) 2, 4
• Alternative NMBA: Rocuronium 0.9-1.2 mg/kg IV (requires sugammadex immediately available) 2, 4, 6

For Hemodynamically Stable Patients:

• Either etomidate or ketamine acceptable as induction agent 2, 4
• Either succinylcholine or rocuronium acceptable as NMBA when no contraindications exist 2, 4

Critical Timing

• Administer sedative-hypnotic agent and NMBA in rapid succession 3, 4
• Always give sedative-hypnotic BEFORE the NMBA to prevent awareness during paralysis 2, 4
• Attempt intubation within 60-90 seconds of medication administration 6

Common Pitfalls and How to Avoid Them

• Using RSI medications during pulseless cardiac arrest - This delays critical airway management and provides no benefit, as the patient is already unconscious 1, 2
• Inadequate preoxygenation in uncooperative patients - Use medication-assisted preoxygenation with ketamine rather than proceeding with inadequate preparation 1, 2
• Administering NMBA before sedative-hypnotic - This causes awareness during paralysis; always sedate first 2, 4
• Using rocuronium without immediately available sugammadex - In "cannot intubate/cannot oxygenate" scenarios, reversal with sugammadex (completed in 3 minutes) may be lifesaving 2, 4
• Underdosing in obese patients - Dose based on actual body weight, not ideal body weight 6

Special Consideration: Rocuronium in Obstetric Emergencies

• Rocuronium 0.6 mg/kg is NOT recommended for rapid sequence induction in Cesarean section patients, as it results in poor or inadequate intubating conditions when intubation is attempted at 60 seconds 6