What are the recommended induction and paralytic agents, with dosing and contraindications, for rapid sequence intubation in an adult patient?

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Rapid Sequence Intubation Medications

Recommended Medication Regimen

For rapid sequence intubation in adults, administer a sedative-hypnotic induction 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 induction agent always given before the paralytic to prevent awareness during paralysis. 1, 2

Induction Agent Selection

Etomidate (First-Line for Hemodynamic Instability)

  • Dose: 0.3 mg/kg IV (range 0.2-0.3 mg/kg) 1, 2
  • Onset: Rapid unconsciousness with minimal hemodynamic effects 2
  • Primary indication: Hemodynamically unstable patients due to favorable cardiovascular profile 1, 2
  • Key advantage: No mortality difference compared to other induction agents (OR 1.17; 95% CI 0.86-1.60) 1
  • Adrenal suppression concern: Transient biochemical suppression occurs but corticosteroid administration following etomidate is NOT recommended—multiple RCTs showed no mortality benefit 1
  • Dosing caution in elderly: Doses >0.3 mg/kg in patients >55 years are associated with oxygen desaturation requiring bag-valve-mask ventilation; use 0.15-0.2 mg/kg in hemodynamically compromised elderly patients 1
  • Side effects: Vomiting in 4-10% of patients; respiratory depression risk increases with higher doses, particularly in older patients 1

Ketamine (First-Line Alternative)

  • Dose: 1-2 mg/kg IV 1, 2
  • Onset: Rapid dissociative sedation 2
  • Primary indication: Alternative first-line agent with sympathomimetic properties that maintain hemodynamic stability 1
  • Special use: Preferred for medication-assisted preoxygenation (delayed sequence intubation) in agitated, delirious, or combative patients who cannot tolerate preoxygenation devices 1, 3
  • Critical pitfall: In critically ill patients with depleted catecholamine stores, ketamine may paradoxically cause hypotension despite sympathomimetic properties 1
  • Sepsis consideration: Pediatric guidelines explicitly recommend ketamine over etomidate in septic shock due to adrenal suppression concerns with etomidate 1

Neuromuscular Blocking Agent Selection

Succinylcholine (First-Line When No Contraindications)

  • Dose: 1-1.5 mg/kg IV (use actual body weight, not ideal body weight) 1, 4
  • Onset: 30-45 seconds 1
  • Duration: 5-10 minutes 1
  • Primary advantage: Rapid onset and short duration allow for quick return of spontaneous respirations if intubation fails 1, 2
  • Absolute contraindications: 1
    • History of malignant hyperthermia
    • Severe burns or crush injury (after first 24 hours)
    • Spinal cord injury
    • Risk of hyperkalemia (particularly in boys <9 years old)
    • Renal failure after 24 hours (due to upregulated acetylcholine receptors and baseline hyperkalemia creating life-threatening cardiac arrest risk) 3
  • Pediatric premedication requirement: Atropine 0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) must be administered before succinylcholine to prevent bradycardia or asystole 1

Rocuronium (First-Line When Succinylcholine Contraindicated)

  • Dose for RSI: 0.9-1.2 mg/kg IV (high-dose regimen) 1, 2, 4
  • Standard dose: 0.6 mg/kg IV provides intubating conditions in median 1 minute with 31 minutes clinical duration 4
  • High-dose advantage: 0.9-1.2 mg/kg provides onset comparable to succinylcholine (median ≈1 minute) with clinical duration of 58-67 minutes 1, 3, 4
  • Mandatory safety requirement: Sugammadex must be immediately available for reversal (within ≈3 minutes) in "cannot intubate/cannot oxygenate" scenarios 1, 2, 3
  • Timing: Wait at least 60 seconds after rocuronium administration before attempting intubation, or use peripheral nerve stimulator to confirm adequate blockade 1
  • Awareness risk: Rocuronium's 30-60 minute duration outlasts ketamine's dissociative effects, creating a window where patients may be paralyzed but inadequately sedated—implement protocolized post-intubation analgosedation immediately after RSI 1

Critical Timing and Administration Sequence

The sedative-hypnotic agent MUST be administered before the neuromuscular blocking agent to prevent awareness during paralysis. 1, 2, 3

  1. Preoxygenate: 3-5 minutes with well-fitted mask in closed-circuit system 3
  2. Administer induction agent: Etomidate or ketamine 1, 2
  3. Immediately administer NMBA: Succinylcholine or rocuronium 1, 2
  4. Wait for full paralysis: 30-45 seconds for succinylcholine, 60 seconds for rocuronium 1
  5. Intubate: Before assisted ventilation begins 2, 3
  6. Confirm placement: Waveform capnography immediately 3
  7. Initiate post-intubation analgosedation: Immediately, especially with rocuronium 1

Special Population Considerations

Severe Hypoxemia (PaO₂/FiO₂ < 150)

  • Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 1, 3
  • High-flow nasal oxygen (HFNO) when difficult laryngoscopy is anticipated 1, 3

Agitated/Uncooperative Patients

  • Medication-assisted preoxygenation (delayed sequence intubation): Ketamine 1 mg/kg IV (titrated with additional 0.5 mg/kg doses to mean total of 1.4 mg/kg) given 3 minutes before NMBA increases mean arterial oxygen saturation by ≈8.9% (95% CI 6.4-10.9%) 1, 3

Renal Failure

  • Induction agent: Etomidate (0.2-0.3 mg/kg) or ketamine (1-2 mg/kg)—neither requires renal dose adjustment 3
  • NMBA: Rocuronium (0.9-1.2 mg/kg) is the neuromuscular blocker of choice; avoid succinylcholine after 24 hours of established renal failure 3

Elderly Patients (≥65 years)

  • Preferred induction agent: Ketamine (1-2 mg/kg) for hemodynamic stability 3
  • Preferred NMBA: Rocuronium (0.9-1.2 mg/kg) over succinylcholine 3
  • Positioning: Semi-Fowler position (head and torso elevated 25-30°) 3
  • Preoxygenation: NIPPV for 3-5 minutes with CPAP 5-10 cm H₂O if severe hypoxemia 3
  • Etomidate caution: Do not exceed 0.3 mg/kg; consider 0.15-0.2 mg/kg in hemodynamically compromised elderly 1

Cervical Spine Injury

  • Perform early RSI with manual inline stabilization after removing anterior portion of cervical collar 3
  • Use bougie during direct laryngoscopy; maintain low threshold for videolaryngoscopy 3

Burn Patients

  • Avoid succinylcholine after first 24 hours post-burn to prevent potentially fatal hyperkalemia 3

Positioning and Preoxygenation

  • Position: Semi-Fowler (head and torso inclined 25-30°) to reduce aspiration risk and potentially improve first-pass success 1, 3
  • Preoxygenation duration: 3-5 minutes with well-fitted mask in closed-circuit system 3
  • Severe hypoxemia: Use NIPPV with CPAP 5-10 cm H₂O 1, 3
  • Anticipated difficult airway: Use HFNO 1, 3

Common Pitfalls and How to Avoid Them

Awareness During Paralysis

  • Never administer NMBA before induction agent—this causes awareness during paralysis 1, 2
  • With rocuronium, implement protocolized post-intubation analgosedation immediately; assign a dedicated team member (preferably clinical pharmacist) to manage timing 1
  • Incidence of explicit recall is approximately 2.6% in emergency intubations, substantially reduced with protocolized post-intubation analgosedation 1

Inadequate Preoxygenation

  • For agitated patients, use medication-assisted preoxygenation with ketamine rather than proceeding with inadequate preoxygenation 1, 3

Hemodynamic Instability

  • Have vasopressors immediately available 1
  • Consider 500 mL crystalloid fluid challenge before or during intubation in absence of overt cardiac failure 3
  • All induction agents can cause vasodilation and hypotension by abolishing sympathetic tone 3

Dosing Errors in Obesity

  • Use actual body weight (not ideal body weight) for succinylcholine dosing 1
  • Patients with BMI >30 kg/m² have twice the risk of intubation-related complications (fourfold if BMI >40 kg/m²) 3

Delayed Post-Intubation Sedation

  • Rocuronium's longer duration (30-60 minutes) versus ketamine's shorter dissociative effects creates high-risk period for awareness if additional sedation not promptly administered 1
  • Standardized order sets should automatically trigger sedation protocols after rocuronium administration 1

References

1
Guideline

Rapid Sequence Intubation Medication Regimen

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Rapid Sequence Intubation Pharmacology

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Rapid Sequence Intubation in Emergency Situations

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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