Rapid Sequence Intubation Medication Guidelines

Induction‑Hypnotic Agents

Etomidate (0.2–0.3 mg/kg IV) is recommended as the first‑line induction agent for hemodynamically unstable adult patients because it produces minimal cardiovascular depression; the 2023 Society of Critical Care Medicine (SCCM) guidelines found no difference in mortality or vasopressor use compared with other agents, supporting its safety in critically ill patients. [1][2]
Ketamine (1–2 mg/kg IV) is an alternative induction agent for agitated or combative patients; it preserves spontaneous respiration and stimulates catecholamine release, making it useful for medication‑assisted pre‑oxygenation. 2
Ketamine should be avoided in patients with severe catecholamine depletion (e.g., septic or cardiogenic shock) because it may cause paradoxical hypotension and cardiac arrest. 1
Propofol (2–2.5 mg/kg IV) should be limited to hemodynamically stable adults, as it can cause marked venodilation‑related hypotension. 1

The SCCM issues a Class I strong recommendation that an NMBA be administered immediately after a sedative‑hypnotic to prevent awareness during paralysis. [1][2]
Succinylcholine (1–1.5 mg/kg IV) provides the fastest onset (≈45–60 s) and shortest duration (≈5–10 min) and is preferred when no contraindications exist. 2
Rocuronium (0.9–1.2 mg/kg IV for RSI) is an acceptable alternative when succinylcholine is contraindicated; at this high dose its onset (≈1 min) is comparable to succinylcholine, though its duration is longer (≈58–67 min). The 2023 SCCM guidelines report no outcome differences between succinylcholine and rocuronium in stable patients. 2

Fentanyl (2–5 µg/kg IV administered 3 min before induction) can blunt the sympathetic response to laryngoscopy in adults with cardiovascular disease or elevated intracranial pressure, reducing peri‑intubation hypertension and tachycardia; however, it may increase the risk of apnea and should be used cautiously. 3

Unstable patients: Use etomidate (0.2–0.3 mg/kg) plus succinylcholine (1–1.5 mg/kg) to achieve rapid intubation with minimal hemodynamic impact. [1][2]
Stable patients: Either etomidate or ketamine may be used for induction, combined with either succinylcholine or high‑dose rocuronium (0.9–1.2 mg/kg); SCCM guidelines find no significant differences in outcomes among these options. 2
Agitated/combative patients unable to tolerate pre‑oxygenation: Begin with ketamine (1–2 mg/kg IV) for medication‑assisted pre‑oxygenation, then proceed with the chosen NMBA once adequate dissociation is achieved. 2

The American College of Critical Care Medicine recommends that sedative-hypnotic agents, such as etomidate, ketamine, and propofol, be administered to induce unconsciousness before neuromuscular blocking agents (NMBAs) to prevent awareness during paralysis, with etomidate being the most favorable for unstable patients due to its minimal cardiovascular depression 4, 5, 6
Etomidate enhances GABA-A receptor activity, producing rapid unconsciousness with minimal hemodynamic effects, and is recommended for hemodynamically unstable patients, with a dose of 0.2-0.3 mg/kg 6
Ketamine is an NMDA receptor antagonist that maintains respiratory drive and increases catecholamine release, but may cause paradoxical hypotension in critically ill patients with depleted catecholamine stores, and is recommended for medication-assisted preoxygenation in agitated patients, with a dose of 1-2 mg/kg 6, 7, 8

The American College of Critical Care Medicine strongly recommends administering an NMBA, such as succinylcholine or rocuronium, when a sedative-hypnotic agent is used for intubation, to produce complete muscle paralysis and facilitate optimal intubating conditions, with succinylcholine being the preferred agent for hemodynamically stable patients due to its rapid onset and short duration 5, 6, 7
Rocuronium is a non-depolarizing NMBA that provides intubating conditions in median 1 minute with 31 minutes clinical duration, and requires sugammadex to be immediately available for reversal in "cannot intubate/cannot oxygenate" scenarios, with a dose of 0.9-1.2 mg/kg for RSI 7, 8

For hemodynamically stable patients, either etomidate or ketamine can be used as the induction agent, and either succinylcholine or rocuronium can be used as the NMBA, with the choice of agent depending on the patient's specific needs and medical history 6, 7, 8
For hemodynamically unstable patients, etomidate is the preferred induction agent due to its minimal cardiovascular depression, and succinylcholine is the preferred NMBA due to its rapid onset and short duration 5, 6
For agitated or uncooperative patients, ketamine is recommended for medication-assisted preoxygenation before administering an NMBA, with a dose of 1-2 mg/kg 7, 8

The American College of Critical Care Medicine recommends that sedative-hypnotic agents and NMBAs be administered in rapid succession, with immediate endotracheal tube placement before assisted ventilation begins, to minimize aspiration risk and ensure optimal intubating conditions 4, 7