Rapid sequence intubation

See critical care quick reference for 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, minimum dose 0.1mg[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 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
  • 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)
    • Vecuronium 10mg, then 7mg/hr

See Also

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.


Ross Donaldson