Rapid sequence intubation

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See critical care quick reference for pre-calculated medication dosages by age and weight.


Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.



There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations[1]


  • 0.02mg/kg, no minimum dose (prior minimum 0.1mg no longer recommended)[2]
  • May prevent bradycardia

Relative indications:

  • Intubation in child < 1 yr old
  • Prior to a second dose of succinylcholine


  • 1.5mg/kg
  • May lower ICP, but need 5-10 minutes prior to RSI


  • 3 mcg/kg
  • Blunts sympathetic response to intubation (pretreat if concern for increased ICP/BP, i.e. ICH, aortic dissection)
  • Should be the last agent given




  • 0.2-0.4mg/kg
  • Onset - 1 min
  • Duration - 30-60 min

Special Considerations:

  • There is concern for adrenal suppression exists regarding etomidate dosing although clinically significant outcomes from transient depression has not been demonstrated. Effects may be greater for pediatric patients[3][4][5]


  • Dose: 0.2-0.3mg/kg
  • Onset - 1 to 2 min
  • Duration - 30-60 min


  • Dose: 1-3mg/kg
  • Duration - 10-15 min


  • Dose: 1-2mg/kg IV or 3-4mg/kg IM
  • Duration - 30 min




  • 1.5mg/kg IV (>10 y/o)
  • 2.0mg/kg IV (<10 y/o)
  • 4mg/kg IM
    • Onset: IV- 45s, IM - 2-3 min
    • Duration: IV - 4-6min, IM - 10-30min



  • 1.2mg/kg (intubation RSI dose)
  • 0.6mg/kg (for repeat paralysis)
  • Onset - 60s
  • Duration- 25-60 min



  • 0.1mg/kg
  • Onset - 60-90 seconds
  • Duration - 65 minutes (95% complete recovery)
  • agent of choice for prolonged paralysis

Trauma RSI

  • Consider decreasing induction agent dosage for hemodynamic compromise
  • Paralytic dosage stays the same
  • Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI[6]
    • Etomidate does not have analgesic properties
    • However, etomidate and succinylcholine produces less hypotension
  • Hemodynamically stable, normotensive, well perfusing
    • Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
    • Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium
  • Hypotensive or poorly perfusing
    • Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
    • Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium

7 Ps


  • SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)


  • Nitrogen wash-out
    • 100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
    • Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated


  • Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg
  • Increased ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
  • Reactive Airway disease: Lidocaine 1.5mg/kg (suppresses cough reflex)
  • Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg)
    • Controversial

Paralysis with induction

    • Etomidate (0.3mg/kg)
      • Especially good for hypotensive/trauma patients
      • Hemodynamically neutral, lowers ICP
      • Lowers seizure threshold in patients with known seizure disorder
      • Does NOT blunt sympathetic reaction to intubation (no analgesic effect)
      • Adrenal suppression is likely irrelevant with one-time dose
    • Ketamine (1-4mg/kg)
      • Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
      • Available in IM form
      • Sympathomimetic
        • Avoid in patient with significant HTN
        • Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
    • Midazolam (0.2mg/kg)
      • Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
      • Consider in patient in status epilepticus (anti-seizure effect)
      • May decrease MAP, especially if patient hypovolemic
    • Propofol (1.5 to 3mg/kg)
      • Consider in patient with bronchospasm
      • Decreases MAP, CPP
    • Succinylcholine
      • 1.5mg/kg - better to overdose than to underdose
      • 2mg/kg - neonates/infants
    • Contraindications
      • Stroke <6 months old, MS, muscular dystrophies
      • ECG changes consistent with hyperkalemia
      • OK to use in crush injury, acute stroke as long as within 3 days of occurrence
    • Rocuronium
      • 1-1.2mg/kg
    • Consider not paralyzing in these situations
      • Expanding neck hematoma, to keep integrity of strap muscles
      • Unable to BVM due to facial hair, micrognathia
      • Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)

Protection and positioning

  • Sniffing position
  • in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as bougie or video laryngoscopy if minimal blood in oropharynx

Pass Tube

  • Intubation
  • End-tidal CO2 detection is primary means of ETT placement confirmation
  • Cola-complication: need CO2 detection for at least 6 ventilations

Postintubation management

  • CXR
  • Non-violent restraints
  • Head of bed to 30° elevation
  • Check ABG 30 minutes post-intubation
  • Sedation
    • Benzos
      • Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
      • Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
    • Propofol
      • 5-80mcg/kg/min (titrate q10min)
  • Analgesia
    • Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
  • Paralysis (if needed)

See Also

Airway Pages

External Links


  1. Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7
  2. AHA 2015 guidelines comparison full text
  3. Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.
  4. Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.
  5. Scherzer D et al. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther JPPT Off J PPAG. 2012;17(2):142-149. doi:10.5863/1551-6776-17.2.142
  6. Lyon RM et al. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1): 134. Published online 2015 Apr 1. doi: 10.1186/s13054-015-0872-2.