What is the safest and easiest medication regimen for rapid‑sequence intubation in a typical adult patient?

Safest and Easiest RSI Medication Regimen

For the typical adult patient, use ketamine 1–2 mg/kg IV followed immediately by rocuronium 1.0–1.2 mg/kg IV, as this combination provides excellent intubating conditions with maintained hemodynamic stability and avoids the adrenal suppression concerns associated with etomidate. 1

Primary Medication Regimen

Induction Agent: Ketamine

• Administer ketamine 1–2 mg/kg IV as your first-line induction agent, using the lower end of the dosing range (1 mg/kg) in patients with cardiovascular compromise 1, 2
• Ketamine maintains hemodynamic stability through sympathomimetic properties that preserve blood pressure via endogenous catecholamine release, making it particularly advantageous in the undifferentiated patient 2
• The 2023 Society of Critical Care Medicine guidelines found no mortality difference between ketamine and etomidate in critically ill patients (OR 0.95; 95% CI 0.72–1.25) 3

Neuromuscular Blocking Agent: Rocuronium

• Administer rocuronium 1.0–1.2 mg/kg IV immediately after ketamine to ensure optimal intubating conditions 1, 4
• Rocuronium at this dose provides excellent intubating conditions within 60–90 seconds, comparable to succinylcholine 4, 5
• Wait at least 60 seconds after rocuronium administration before attempting intubation 1

Critical Post-Intubation Protocol

Immediate Analgosedation (Most Important Safety Step)

• Implement protocolized post-intubation analgosedation immediately after successful intubation to prevent awareness during the 30–60 minute duration of rocuronium-induced paralysis, which far outlasts ketamine's dissociative effects 1
• The incidence of explicit recall during emergency intubation is approximately 2.6%, and this risk is substantially reduced when immediate post-intubation sedation protocols are followed 1, 2
• Assign a dedicated team member (ideally a clinical pharmacist) to manage post-intubation analgosedation timing 1
• The median time to first analgosedative intervention should be approximately 7 minutes (IQR 3–13 minutes) 6

Alternative Regimen: Etomidate-Based

When to Consider Etomidate

• Etomidate 0.2–0.3 mg/kg IV remains an acceptable alternative in hemodynamically unstable patients, though it offers no mortality advantage over ketamine 1, 2
• Use the lower dose (0.15–0.2 mg/kg) in patients with hemodynamic compromise 1
• Critical dosing caveat: Do not exceed 0.3 mg/kg in patients over 55 years, as higher doses are associated with oxygen desaturation requiring bag-valve-mask ventilation 1

Etomidate Considerations

• Despite causing transient adrenal suppression, corticosteroid administration following etomidate is NOT recommended, as multiple RCTs showed no mortality benefit 1
• Etomidate may cause pain on injection, myoclonic movements, hiccups, nausea, and vomiting 7

Alternative Neuromuscular Blocker: Succinylcholine

When to Use Succinylcholine

• Succinylcholine 1–1.5 mg/kg IV is an alternative when rocuronium is unavailable or when shorter duration of paralysis (5–10 minutes) is desired 1
• Onset is 30–45 seconds, slightly faster than rocuronium 1
• The shorter duration eliminates the awareness risk window that exists with rocuronium 1

Succinylcholine Contraindications

• Contraindicated in patients with history of malignant hyperthermia, severe burns or crush injury, spinal cord injury, or risk of hyperkalemia 1

Essential Safety Measures

Hemodynamic Preparation

• Have vasopressors immediately available during RSI with any induction agent, as post-intubation hypotension is common and associated with increased mortality 2, 3
• In critically ill patients with depleted catecholamine stores (prolonged septic shock, severe cardiogenic shock), ketamine may paradoxically cause hypotension despite its sympathomimetic properties 1, 3

Dosing by Body Weight

• Dose all RSI medications based on actual body weight, not ideal body weight, as this is critical for optimal intubating conditions 1, 4
• Obese patients dosed by ideal body weight had longer time to maximum block and shorter clinical duration 4

Preoxygenation

• Position the patient in semi-Fowler position (head and trunk inclined) during RSI to improve first-pass success 1
• Use high-flow nasal oxygen when challenging laryngoscopy is anticipated 1

Special Population Considerations

Head-Injured Patients

• Ketamine is safe and appropriate for RSI in head-injured patients when used with controlled mechanical ventilation 3
• Historical concerns about ketamine increasing intracranial pressure have been refuted by evidence from 2009–2013 3

Septic Patients

• Strongly prefer ketamine over etomidate in septic patients, particularly in pediatric populations where guidelines explicitly recommend against etomidate 1

Obstetric Patients

• Rocuronium is NOT recommended for rapid sequence induction in Cesarean section patients due to inadequate intubating conditions when attempted at 60 seconds with lower thiopental doses 4

Common Pitfalls to Avoid

• Never administer the neuromuscular blocker before the induction agent, as this causes awareness during paralysis 1
• Never forget post-intubation analgosedation when using rocuronium, as the 30–60 minute paralysis duration far exceeds ketamine's sedative effects 1
• Never use propofol in hemodynamically unstable patients, as it has the most profound effect on blood pressure among induction agents 2
• Never dose obese patients by ideal body weight, as this results in inadequate intubating conditions 1, 4