Rapid Sequence Intubation with Succinylcholine, Ketamine, and Midazolam

Medication Components for RSI

The Society of Critical Care Medicine guidelines recommend administering either rocuronium or succinylcholine for RSI, with succinylcholine being an appropriate choice when there are no contraindications 1, 2
Ketamine is an appropriate induction agent for RSI due to its quick onset and short duration of action, preservation of respiratory drive, and sympathomimetic properties that help maintain hemodynamic stability 3
Guidelines advise administering a sedative-hypnotic induction agent when an NMBA is used for intubation, with ketamine being a suitable option 4, 5

A sedative-hypnotic agent, such as ketamine, should be administered before the neuromuscular blocking agent, succinylcholine, to prevent awareness during paralysis 5, 6
Failure to provide adequate sedation before paralysis can result in awareness during paralysis, which occurs in approximately 2.6% of emergency department intubations 6

Ketamine's sympathomimetic properties make it particularly valuable in hemodynamically unstable patients 3
Midazolam doses should be reduced in hemodynamically unstable patients due to its vasodilatory effects, although the primary source for this fact is from a less preferred journal, a similar fact can be inferred from 3

Etomidate (0.2-0.4 mg/kg) can be considered as an alternative to ketamine when contraindicated, as it provides relatively stable hemodynamics, according to the American Society of Anesthesiologists 7, 8

Succinylcholine (1.5 mg/kg) is recommended as the first-line neuromuscular blocking agent for RSI in patients with vital signs of distress, as suggested by the Society of Critical Care Medicine 7, 9
Rocuronium (0.9-1.2 mg/kg) should be used when succinylcholine is contraindicated, as recommended by the American College of Emergency Physicians 7, 9

A recruitment maneuver and application of at least 5 cmH2O PEEP after intubation can improve oxygenation, as suggested by the American Thoracic Society 7

Ketamine may have a higher risk of hypotension compared to etomidate in some patient populations, with one study finding higher rates of hypotension with ketamine (18.3% vs 12.4%), according to the Society of Critical Care Medicine 10