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Rapid Sequence Intubation Drugs
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Sedative induction agents used in RSI 
Agent IV Dose Onset Duration
Thiopental 3 - 5 mg/kg  10 - 40 secs 10 - 20 mins
Methohexital 1.5 mg/kg 30 - 60 secs 5 - 10 mins
Etomidate 0.3 mg/kg 30 - 45 secs 10 - 20 mins
Propofol 1 - 2 mg/kg 10 - 30 secs 8 - 10 mins
Ketamine 1 - 2 mg/kg 30 - 60 secs 5 - 20 mins
Midazolam 0.1 - 0.3 mg/kg 2 - 3 mins 20 - 30 mins

Sedative induction agents used in RSI - advantages, disadvantages and contra-indications
Agent Advantages Disadvantages Contra-indications
Thiopental
  • rapid onset
  • brief duration
  • decreases ICP
  • anticonvulsant
  • decreases blood pressure
  • myocardial depression
  • respiratory depression
  • histamine release
  • no analgesic effect
  • hypotensive patient
  • asthmatic patient
  • porphyria
Methohexital
  • very rapid onset
  • very short duration
  • decreases ICP
  • decreases blood pressure
  • respiratory depression
  • seizures (rare)
  • hypertonus/hiccuping
  • laryngospasm
  • no analgesic effect
  • hypotensive patient
  • ? seizure disorder
  • porphyria
Etomidate
  • no deleterious effect on blood pressure
  • minimal depression of respiration
  • decreases ICP and IOP
  • myoclonic movements
  • seizures
  • hiccups
  • nausea/vomiting
  • decreases steroid synthesis
  • minor pain on injection
  • no analgesic effect
  • ? focal seizure disorder
  • adrenal insufficiency
  • should not be used as a continuous IV sedating agent, because it depresses steroid synthesis
Propofol
  • decreases ICP
  • titratable - useful for maintenance sedation
  • anti-emetic
  • anti-convulsant
  • decreases blood pressure
  • myocardial depression
  • respiratory depression
  • myoclonic movements
  • minor pain on injection
  • rare bronchospasm
  • no analgesic effect
  • hypotensive patient
  • ? asthmatic patient
Ketamine
  • "dissociative" anesthesia without impairing airway reflexes
  • analgesia ++
  • amnesia
  • bronchodilator
  • no decrease in blood pressure - useful in hypotensive patients
  • no significant respiratory depression
  • increases ICP
  • ? minimally increases IOP
  • increases airway secretions
  • laryngospasm
  • increases blood pressure
  • increases heart rate
  • increases muscle tone
  • nausea/vomiting
  • emergence reactions
  • uncontrolled hypertension
  • increased ICP
  • penetrating eye injury
  • glaucoma
  • acute URI
  • ? CAD/CHF
  • history of psychosis
  • thyroid storm
Midazolam
  • amnesia ++
  • anti-convulsant
  • delayed onset
  • inconsistent effect
  • respiratory depression
  • hypotension - variable and dose-dependent
  • hypotensive patient

Sedative induction agents suitable for different clinical scenarios
Clinical scenario Suitable options (in order of preference)
Normotensive/euvolemic Etomidate, thiopental, propofol, midazolam
Mild hypotension + head injury Etomidate, thiopental, propofol, midazolam
Mild hypotension + no head injury Etomidate, ketamine, low dose midazolam
Severe hypotension Ketamine, half-dose etomidate (0.15mg/kg), very low dose midazolam (0.05 - 0.1mg/kg)
Status asthmaticus Ketamine, etomidate, propofol
Status epilepticus Thiopental, propofol, midazolam
Isolated head injury Etomidate, thiopental, propofol
Cardiogenic pulmonary edema Etomidate, low dose midazolam

Muscle relaxants used in RSI
Agent IV Drug dose Time to intubation Duration
Succinylcholine 1.5 mg/kg 
(peds - 2 mg/kg)
45 - 60 secs 6 - 12 mins
Rocuronium 1.0 mg/kg  45 - 75 secs 30 - 60 mins
Rapacuronium 1.5 mg/kg
(peds  - 2 mg/kg if < 12 years)
45 - 75 secs 20 - 30 mins
(8 - 10 mins if reversed with 0.05mg/kg of neostigmine)

Muscle relaxants used in RSI - advantages, disadvantages and contra-indications
Agent Advantages Disadvantages Contra-indications
Succinylcholine
  • rapid onset
  • short duration
  • reliable
  • bradyarrhythmias
  • increases serum potassium
  • increases intragastric pressure (mild)
  • increases IOP (minimal)
  • increases ICP (? significance)
  • masseter spasm (rare)
  • malignant hyperthermia (rare)
  • fasciculation-induced muscle pain
  • prolonged effect in plasma pseudocholinesterase deficiency states
  • hyperkalemia-induced cardiac arrest in children with undiagnosed myopathy (very rare)
  • difficult airway and insecurity about the ability to sucessfully BVM the patient
  • family or personal history of malignant hyperthermia
  • known hyperkalemia
  • certain chronic muscle  dystrophies, prior spinal cord injury, prior strokes, any demyelinating diseases
  • pre-existing tissue injury > 3 days prior to RSI
  • burns > 24 hours prior to RSI
  • increased ICP
  • ? head injury (relative)
  • ? open globe injury (relative)
  • renal failure with hyperkalemia (absolute)
  • renal failure without hyperkalemia (relative)
Rocuronium
  • no effect on serum potassium
  • no bradycardia
  • no fasciculation
  • slightly delayed onset
  • long duration
  • tachycardia - mild vagolytic effect
  • difficult airway and insecurity about the ability to sucessfully BVM the patient
Rapacuronium
  • no effect on serum potassium
  • no bradycardia
  • no fasciculation
  • longer duration (duration can be decreased ~ 50% with neostigmine - 0.05 mg/kg)
  • releases histamine
  • new drug - experience is still limited
  • difficult airway and insecurity about the ability to sucessfully BVM the patient
  • ? asthma

Post-intubation maintenance sedation
Sedative Intermittent bolus (mg/kg) Infusion (mcg/kg/hour)
Diazepam 0.1 - 0.15  
Lorazepam 0.05 - 0.1  
Midazolam 0.05 - 0.1  
Propofol 1 - 1.5 10 - 30