Rapid sequence induction

This chapter will review the pharmacotherapy for management of rapid sequence induction outside the operating room according to expert opinion.


Rapid sequence induction is the administration of an induction agent (anesthetic) and a neuromuscular blocking agent to rapidly produce unconsciousness and muscular paralysis to facilitate endotracheal intubation.


See Table 23.1 .

Table 23.1

Pharmacotherapy for Rapid Sequence Induction (RSI)

Data from Mosier JM, Sakles JC, Stolz U, et al. Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit: a propensity matched analysis. Ann Am Thorac Soc . 2015;12(5):734–741; and from Sakles JC, Douglas MJK, Hypes CD, et al. Management of patients with predicted difficult airways in an academic emergency department. J Emergency Med . 2017;53(2):163–171.

Induction Agents

  • Etomidate

  • 0.3 mg/kg

  • Shock: 0.15 mg/kg

  • Onset: 30–45 s

  • Duration: 5–15 min

  • May suppress adrenal cortisol production; use cautiously in sepsis; consider hydrocortisone 100 mg IV ×1

  • Minimal hypotension; ideal for hemodynamic instability

  • Ketamine

  • 1–2 mg/kg

  • Shock: 1 mg/kg

  • Onset: 45–60 s

  • Duration: 10–20 min

  • Beneficial in bronchospasm, septic shock, and hemodynamic compromise

  • Minimal respiratory depression

  • Causes catecholamine release, stimulant effects

  • CI: elevated ICP or BP

  • Midazolam

  • 0.1–0.3 mg/kg

  • Onset: 30–60 s

  • Duration: 15–30 min

  • Amnesic properties

  • Dose-related hypotension

  • Propofol

  • 1.5–2.5 mg/kg

  • Onset: 15–45 s

  • Duration: 5–10 min

  • Bronchodilation

  • Respiratory depression, dose-related hypotension

Neuromuscular Blocking Agents

  • Succinylcholine

  • 1–1.5 mg/kg

  • Use total BW

  • Onset: 30–60 s

  • Duration: 5–10 min

  • Depolarizing NMBA

  • Second dose can cause bradycardia (treat with atropine, see Table 3.1 )

  • NMBA of choice except for malignant hyperthermia, neuromuscular disease, muscular dystrophy, stroke or burn over 48 h old, rhabdomyolysis, significant hyperkalemia

  • Rocuronium

  • 1 mg/kg

  • Use ideal BW

  • Onset: 45–60 s

  • Duration: 30–45 min

  • Preferred nondepolarizing NMBAs due to shorter onset and duration compared to other agents in the same class

  • Vecuronium

  • 0.1 mg/kg

  • Onset: 3–4 min

  • Duration: 35–45 min

  • Alternative nondepolarizing NMBA to rocuronium


  • Pancuronium is not recommended due to tachycardia and histamine release and longer onset and duration compared to other NMBAs

  • Sugammadex:

    • A reversal agent for rocuronium and vecuronium; a rescue agent if unable to intubate/ventilate

    • Routine reversal of rocuronium or vecuronium: 2–4 mg/kg

    • Immediate reversal of rocuronium: 16 mg/kg

    • Risk of bradycardia: monitor electrocardiogram

    • Risk of anaphylaxis: have resuscitation drugs readily available

    • Use not recommended in CrCl <30 and dialysis

  • Neostimine

    • A reversal agent for nondepolarizing NMBAs

    • Only give when there is adequate recovery (train-of-four ≥10% of baseline)

    • Dose: 0.05–0.07 mg/kg IV ×1

    • Glycopyrrolate IV (0.2 mg for each 1 mg of neostigmine) should be given prior to or in conjunction with neostigmine

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Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Rapid sequence induction

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