RAPID SEQUENCE INTUBATION MEDICATION GUIDE

Induction/Sedatives
Drug Dose Adverse Effects Indications/Comments
Etomidate 0.3 mg/kg IV Adrenal insufficiency, pain on -Used in almost all patients for emergency RSI.
injection, myoclonic activity -Consider an alternative agent if patient in septic shock or status
Common order 20mg epilepticus
Ketamine 1-2 mg/kg IV Increased BP/HR/IOP -Good option for patients with reactive airway disease or who are
hypovolemic, hemorrhaging, or in shock
Common Dose 100 mg -Avoid in patients that are normotensive or hypertensive.
-Use caution in patents with cardiovascular disease
Propofol 1.5 mg/kg – 3mg/kg IV Hypotension, myocardial -For hemodynamically stable patients with reactive airway disease
depression, reduced cerebral or status epilepticus
Not Commonly used perfusion pressure, pain on -Very short acting. Effects on BP limit use for RSI induction.
injection
midazolam (Versed) 0.1-0.3 mg/kg IV Respiratory depression, -Not recommended or routinely used for induction
paradoxical agitation; -Patient response may be extremely variable
Common Dose 5mg hypotension -May use for post-intubation management
Paralytic Agents
Agent Dose Adverse effects Indications/Comments
Succinylcholine 1-1.5 mg /kg IV Hyperkalemia -Essentially all patients except those with malignant hyperthermia,
2mg/kg IM Muscle fasciculation hyperkalemia
Elevated IOP -Bradycardia may occur after repeated doses, have atropine ready
Common dose 100 mg in the event
Rocuronium 0.6-1.2mg/kg IV No clinically significant AEs -RSI when succinylcholine contraindicated
-Ensure contingency plan in the event of failed airway
Common dose 80-100mg
Other Medications
Drug Dose Adverse Effects Indications/Comments
Phenylephrine 100 – 200 mcg IV every 10-15 Reflex bradycardia -For hypotension during/post intubation
min prn
Fentanyl 50mcg-100mcg Pre-intubation treatment to reduce the release of catecholamines
 "Seven Ps of RSI"

Preparation Patient is assessed to predict the difficulty of intubation. Continuous monitoring EKG and Pulse Ox. RSI drug box is obtained and drugs should be prepared
in syringes. IVs should be flushed for patency. Two IV access or more is best practice. RT will gather the laryngoscope and assesses for proper endotracheal tube size.
Preoxygenation This provides an oxygen reserve in the lungs that will delay the depletion of oxygen in the absence of ventilation (after paralysis). For a healthy adult, this
can lead to maintaining a blood saturation of at least 90% for up to 8 minutes. This time will be significantly reduced in obese patients, ill patients and children.
 Performed by giving 100% oxygen via a tightly fitting face mask eight deep breaths over 60 seconds
 Use of non-rebreather placed on the patient at 15 LPM at least 5 minutes prior to the administration of the sedation and paralytic drugs.
Pretreatment Intubation causes increased sympathetic activity, an increase in intracranial pressure and bronchospasm. Patients with reactive airway disease, increased
intracranial pressure (Stroke/Trauma), or cardiovascular disease may benefit from pretreatment.
Three common medications used in the pretreatment of RSI include:
 Neosynephrine (phenylephrine) to increases blood pressure in hypotensive or low blood pressure prior to intubation 0.50-1.0mcg/kg
 Lidocaine has the ability to suppress the cough reflex which in turn may ease increased intracranial pressure. The typical dose for Lidocaine prior to
intubation is 1.5 mg/kg IV given three minutes prior to intubation.
 Atropine may also be used as a premedication agent in pediatrics to prevent bradycardia caused by hypoxia, laryngoscopy, and succinylcholine.
Atropine is parasympathetic blocker. The common premedication dose for atropine is 0.01-0.02 mg/kg.
Positioning Positioning involves bringing the axes of the mouth, pharynx, and larynx into alignment, leading to what's called the "sniffing" position. The sniffing
position can be achieved by placing a rolled towel underneath the head and neck, effectively extending the head and flexing the neck. You are at proper alignment when the ears
are in line with the sternum.
Paralysis The induction drug 1st (example Etimodate/Ketamine) and neuromuscular blocking agent 2ND (Rocuronium, Vecuronium, Succinylcholine) are administered
in rapid succession with no time allowed for manual ventilation.
Placement of tube During this stage, laryngoscopy is performed to visualize the glottis. Modern practice involves the passing of a ‘Bougie’, a thin tube, passed the vocal cords
and over which the endotracheal tube is then passed. The Sellick's maneuver, or cricoid pressure, may be used to occlude the esophagus with the goal of preventing aspiration. The
bougie is then removed and an inbuilt cuff at the end of the tube is inflated with a 10cc syringe, to hold it in place and prevent aspiration of stomach contents.
Postintubation management Malpositioning of the endotracheal tube (in a bronchus, above the glottis, or in the esophagus) should be assessed by:
 confirmation of end tidal CO2
 auscultation of both lungs and stomach (Auscultate stomach first if breath sounds heard, then the tube is misplaced) and Observation of bilateral chest
rise. If unilateral think possible pneumothorax
 STAT ORDER FOR CHEST XRAY to verify tube placement.
 Need to request from provider sedation order, important to consider the ½ life of your sedation given prior to intubation, continue sedation prior to the
patient waking under a paralytic. Common protocol is fentanyl 50mcg-100cmg pushes every 15 minutes for one hour if blood pressure can tolerate.
 Blood pressure can drop due to placement of ET tube or use of sedation. The RSI kits have Neosynephrine in prefilled syringes, for stat pushes typical dose
is 300mcg (3cc) every 15 minutes, however will need to discuss with provider how to manage hypotension may require continuous drip.