RSI is rapid sequence intubation, a procedure performed to emergently intubate a patient with an intact gag reflex in cases of acute respiratory failure and/or cardiovascular collapse. As a nurse working in the emergency department or ICU, you will be obtaining and, in many cases, administering the medications used to perform a rapid sequence intubation. Please be aware of your scope of practice and facility protocol regarding the administration of these medications. In some cases, the medications can only be administered by a physician. 

Which combination of medications the physician chooses will vary depending on a variety of factors including the patient’s condition and physician preference. A common combination is a sedative with a short-acting paralytic, though analgesics may also be utilized. 

The common selection of medications utilized for RSI include:

Propofol

Propofol acts on GABA receptors to provide sedation and amnesia, and it does not have an analgesic effect. Because propofol’s sedating effects occur by suppressing brain activity, it is a common induction agent for patients with brain injury, though care must be taken to avoid hypotension. Due to its ability to reduce airway resistance, propofol may be especially beneficial for individuals with bronchospasm. Despite these benefits, propofol does cause myocardial depression, vasodilation, and a decrease in mean arterial pressure so it is used cautiously or not at all in patients with hemodynamic compromise. 

Onset: 40 seconds

Duration: 3 to 5 minutes

Watch out for: Hypotension

Succinylcholine

Succinylcholine is a neuromuscular blocking or paralytic agent. Medications that cause neuromuscular blockade have shown to increase the success rate for RSI while reducing the incidence of complications. Note that patients are always sedated when a paralytic is used, otherwise the patient would be unable to move yet acutely aware of their situation. This can lead to significant distress, tachycardia, hypertension, and increased ICP. Because succinylcholine causes a transient shift of potassium outside the cell, it is avoided in hyperkalemia or in patients at high risk for hyperkalemia such as those with rhabdomyolysis. It is also avoided in patients who are predisposed to malignant hyperthermia as it is a known triggering agent for this life-threatening complication.

Onset: 30 to 60 seconds

Duration: 4 to 10 minutes

Watch out for: Hyperkalemia, malignant hyperthermia, bradycardia

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Rocuronium

Rocuronium is a nondepolarizing neuromuscular blocking agent that is utilized when succinylcholine is contraindicated or when a longer duration of action is desired. If the patient is known to have a difficult airway, nondepolarizing agents are generally avoided. Two adverse effects to be aware of with rocuronium are bronchospasm and anaphylaxis.

Onset: 45 to 60 seconds

Duration: 30 to 45 minutes

Watch out for: Anaphylaxis and bronchospasm

Vecuronium

Vecuronium is another nondepolarizing neuromuscular blocking agent. Is not as widely used as rocuronium due to its longer onset of action, which can be up to three minutes. To help offset this, the MD may order an initial “priming” dose that does not induce paralysis approximately three minutes before the main dose is administered. When a priming dose is used, the onset of action is much faster.

Onset: 75 to 90 seconds when priming dose is used (three minutes without priming dose)

Duration: 30 to 40 minutes

Watch out for: Hypoxia if no priming dose is used, bronchospasm, anaphylaxis

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Etomidate is a sedative-hypnotic agent that acts on GABA receptors to block neuroexcitation while producing anesthesia. It does not provide analgesia or cause hypotension, though it can cause adrenal suppression and myoclonus, which is often mistaken for seizure activity. Because etomidate does not cause hypotension, it is often used in hypotensive patients and in patients for whom hypotension would be especially dangerous. 

Onset: 30 to 60 seconds

Duration: 3 to 5 minutes

Watch out for: Myoclonus, laryngospasm, arrhythmias

Ketamine

Ketamine is a dissociative anesthetic that provides both analgesia along with amnesia and sedation. Since it does not cause respiratory depression, it is often utilized for “awake” intubation in patients with a difficult airway. It is also a hemodynamically stable medication, making it especially useful in hypotensive patients. The catecholamine-release associated with ketamine theoretically causes bronchodilation, though the evidence supporting this is limited. Regardless, ketamine may be utilized in patients with severe asthma for this reason. Note that some patients may experience “emergence phenomenon” in which they have vivid dreams that can be disturbing as they wake up from ketamine-induced anesthesia. However, since most patients undergoing RSI continue to be sedated for a period of time, this is less of a concern.

Onset: 30 seconds

Duration: 5 to 10 minutes

Watch out for: Hypertension, tachycardia, emergence phenomenon

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Fentanyl

An opioid analgesic such as fentanyl may be utilized in some cases. For example, the catecholamine release associated with intubation can cause hypertension which may be dangerous for patients with aortic dissections or other cardiovascular disease. You most often will see fentanyl utilized in coordination with etomidate or succinylcholine to provide sedation and analgesia.

Onset: 1 to 2 minutes

Duration: 30 to 60 minutes

Watch out for: Hypotension

Benzodiazepines

Benzodiazepines such as midazolam cause sedation and amnesia by acting on GABA receptors, but do not provide analgesia. Due to its antiseizure effects, midazolam is an effective choice for RSI in patients with status epilepticus. At its usual dose of 0.2 mg/kg, midazolam can cause a decrease in mean arterial pressure of 10 to 25 percent. Its propensity to cause hypotension means it is not the agent of choice in cases of pre-intubation hypotension, hypovolemia or shock, though lower doses may be utilized if necessary. 

Onset: 90 seconds

Duration: 2 to 6 hours (some sources state 15 to 30 min)

Watch out for: Hypotension

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References:

Caro, D. (2022, February 24). Induction agents for rapid sequence intubation in adults for emergency medicine and critical care – UpToDate. UpToDate. https://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adults-for-emergency-medicine-and-critical-care#H5
Chraemmer-Jørgensen, B., Hertel, S., Strøm, J., Høilund-Carlsen, P. F., & Bjerre-Jepsen, K. (1992). Catecholamine response to laryngoscopy and intubation. The influence of three different drug combinations commonly used for induction of anaesthesia. Anaesthesia, 47(9), 750–756. https://doi.org/10.1111/j.1365-2044.1992.tb03252.x
Davis’s Drug Guide. (n.d.-a). Etomidate (Amidate). Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51812/all/etomidate?refer=true
Davis’s Drug Guide. (n.d.-b). Ketamine (Ketalar). Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51426/all/ketamine?refer=true
Davis’s Drug Guide. (n.d.-c). Midazolam (Nayzilam, Seizalam). Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51501/all/midazolam?refer=true
Davis’s Drug Guide. (n.d.-d). Rocuronium (Zemuron). Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/109873/all/rocuronium?refer=true
Davis’s Drug Guide. (n.d.-e). Vecuronium (Norcuron). Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/109869/all/vecuronium?refer=true
Hausburg, M. A., Banton, K. L., Roman, P. E., Salgado, F., Baek, P., Waxman, M. J., Tanner, A., Yoder, J., & Bar-Or, D. (2020). Effects of propofol on ischemia-reperfusion and traumatic brain injury. Journal of Critical Care, 56, 281–287. https://doi.org/10.1016/j.jcrc.2019.12.021
SBM – Society of Behavioral Medicine. (n.d.). Coronasomnia: Keeping Good Sleep Hygiene During the Pandemic. SBM – Society of Behavioral Medicine. https://www.sbm.org/healthy-living/coronasomnia-keeping-good-sleep-hygiene-during-the-pandemic?gad_source=1&gclid=CjwKCAiAvJarBhA1EiwAGgZl0Gy3DaDjXARkpsDKlm39UhNC1GWsTSkmJmAa9e1IF_7NM1NaXXZI_BoCBZkQAvD_BwE
SCDEHC. (2005). Rapid Sequence Intubation. SCDEHC. https://scdhec.gov/sites/default/files/docs/Health/docs/rsi.pdf
Smischney, N. J., Demirci, O., Diedrich, D. A., Barbara, D. W., Sandefur, B. J., Trivedi, S., McGarry, S., & Kashyap, R. (2016). Incidence of and Risk Factors For Post-Intubation Hypotension in the Critically Ill. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, 22, 346–355. https://doi.org/10.12659/MSM.895919
UMKC School of Medicine. (n.d.). Rapid Sequence Intubation: Medications, dosages, and recommendations. UMKC School of Medicine. https://med.umkc.edu/docs/em/intubation_chart.pdf