Overview of some common RSI agents

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Airway Management – Rapid Sequence Induction – Commonly Used Agents
1. Pre-Medication Agents
Lidocaine
Class 1b Antiarrhythmic – Na channel blocker
Indications: Cardiac arrest – Alternative to amiodarone
RSI – has been shown to blunt raise in ICP associated with suctioning & laryngeal
stimulation.
Anaesthesia – potent local anaesthetic
Ventricular arrhythmias – wide complex tachycardia, PVCs
Effects: Local anaesthetic effects, PVC suppression, slows AV node conduction
Side Effects: Drowsiness, slurred speech, seizures, confusion, hypotension, bradycardia, AVB, nausea,
vomiting, respiratory/cardiac arrest
Contraindications: 2nd
° & 3rd
° AVB, bradycardia, Stokes-Adams Syndrome. Reduce dose by 50% if patient
>70yrs, hepatic dx, CHF or shock
Dose: Cardiac Arrest - 1-1.5mg/kg. Max dose 3.0mg/kg.
RSI – 1.5mg/kg 2-3 minutes prior to intubation
Wide-complex tachy/VT – 1-1.5mg/kg. Max dose 3.0mg/kg.
PVCs – 0.5-1.5mg/kg. Max dose 3.0mg/kg.
Onset of Action: < 3 minutes
Duration of Action: 10-20 minutes
Atropine Sulfate
Anticholinergic
Indications: Symptomatic bradycardia – haemodynamically significant bradycardia with associated
hypotension, dysnpoea, chest pain, altered LOC, CHF, shock
RSI – all paeds < 1 yr to combat reflex bradycardia, ; consider in paeds 1-10 yrs; adults
prior to 2nd
dose succinylcholine; adults with HR <60 prior to laryngoscopy;
Cholinergic Toxidrome – organophosphate poisoning, nerve gas exposure
Asthma – potent bronchodilator
Effects: Parasympathetic stimulation, blocks ACh receptors
Side Effects: Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, confusion, headache
Contraindications: Tachycardia, glaucoma
Dose: Symptomatic bradycardia – 0.5-1mg IVP every 3-5 mins. Max dose 3mg
Cholinergic Toxidrome – 1-5mg IV/IO prn x 5 mins (double dose if IM)
Asthma – 0.4-2mg nebulised in 3ml NaCl
Paed Dose: RSI – 0.02mg/kg, min 0.1mg
Onset of Action: Immediate
Duration of Action: 4 hours

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Fentanyl
Narcotic Analgesic – acts on μ opiate receptors
Indications: Analgesia
RSI
Effects: Analgesia, sedation, less emetic effects than other opioids. Can reduce the sympathetic
response to laryngoscopy.
Side Effects: Respiratory depression, apnoea, muscle rigidity, bradycardia, respiratory arrest, CNS
depression, hypotension, nausea, vomiting
Contraindications: Severe haemorrhage, shock, known hypersensitivity, MAOI use, asthma, myasthenia
gravis. Reduce dose in paeds, geriatrics and high-risk patients
Dose: 2-3mcg/kg slow IV
Onset of Action: 3-5 minutes
Duration of Action: 30-60 minutes
2. Sedative Agents
Etomidate
Sedative, hypnotic
Indications: RSI – rapid onset, short duration, stable haemodynamic profile. Has cerebroprotective
properties, reducing CBF and metabolism in cases of raised ICP.
Effects: Rapid induction of anaesthesia
Side Effects: Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, confusion, headache
Contraindications: Hypersensitivity
Dose: RSI – 0.2-0.6mg/kg, min 0.1mg. Usual dose 0.3mg/kg
Onset of Action: 15-45 seconds
Duration of Action: 3-12 minutes
Midazolam
Benzodiazepine - sedative, hypnotic
Indications: RSI
Seizures
Effects: Sedation, amnesia,
Side Effects: Laryngospasm, bronchospasm, dyspnoea, respiratory depression, drowsiness, amnesia,
altered LOC, bradycardia, tachycardia, PVCs, retching
Contraindications: Hypersensitivity, glaucoma, shock, alcoholic coma
Dose: 2-3mcg/kg slow IV
Onset of Action: 1-15 minutes (IV-IM)
Duration of Action: 1-6 hours (IV-IM)

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Ketamine
NMDA antagonist - anaesthetic, analgesic
Indications: RSI – dissociative induction agent
Analgesia – sub-anaesthetic doses can provide rapid pain relief
Effects: Dissociation, analgesia, anaesthesia, amnesia, bronchodilatory properties, HTN and
tachycardia can be useful in pts. who’s haemodynamic status is unknown
Side Effects: Hallucinations, increased muscle tone, nausea, vomiting, increase in bronchial secretions,
hypertension, respiratory depression, tachycardia, delirium, confusion, raised ICP
Contraindications: Hypertension, hypersensitivity
Dose: 1-2mg/kg IV every 10-20 minutes
Onset of Action: 45-60 seconds
Duration of Action: 4 hours
Propofol
Sedative, hypnotic
Indications: RSI – induction and maintenance of anaesthesia
Sedation: Maintenance of sedation
Effects: Ultra short acting sedation, amnesia, anaesthesia, decreases cerebral oxygen demand and
ICP – however, this can reduce CPP
Side Effects: Local site pain, respiratory depression, hypotension, bradycardia, transient apnoea,
nausea, vomiting, headache
Contraindications: Hypersensitivity, raised ICP, egg/soy sensitivity
Dose: RSI: 2mg/kg IV induction; followed by 25-75 mcg/kg/min infusion.
Sedation: 0.5-1mg/kg IV
Onset of Action: 10-45 seconds
Duration of Action: 5-10 minutes
3. Paralytic Agents
Succinylcholine
Depolarizing neuromuscular blocking agent
Indications: RSI – paralytic agent
Effects: Binds to ACh receptor sites, resistant to AChE, muscle paralysis followed by flaccidity
Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus
arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure,
increased ICP, malignant hyperthermia, raised K+, fasciculations
Contraindications: Hypersensitivity, penetrating eye injuries, glaucoma
Dose: 1-2mg/kg IV
Onset of Action: 30-60 seconds
Duration of Action: 5-10 minutes

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Vecuronium
Non-depolarizing neuromuscular blocking agent
Indications: RSI – paralytic agent (derivative of pancuronium)
Effects: Competes with ACh at nAChR sites, more potent than pancuronium
Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus
arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure,
increased ICP, malignant hyperthermia
Contraindications: Hypersensitivity, penetrating eye injuries, glaucoma
Dose: 0.1mg/kg IV
Onset of Action: 90-120 seconds
Duration of Action: 60-75 minutes
Rocuronium
Non-depolarizing neuromuscular blocking agent
Indications: RSI – paralytic agent
Effects: Binds competitively at ACh sites, antagonising action of Ach, resulting in paralysis
Side Effects: Bronchospasm, hypertension, tachycardia
Contraindications: Hypersensitivity, impaired hepatic/respiratory function, severe obesity
Dose: 0.6-1.2mg/kg IV; maintenance dose 0.1-0.2mg/kg continuous infusion
Onset of Action: <120 seconds
Duration of Action: 30-60 minutes
Pancuronium
Non-depolarizing neuromuscular blocking agent
Indications: RSI – paralytic agent (derivative of curare)
Effects: Competes with ACh at nAChR sites, resulting in paralysis
Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus
arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure,
increased ICP
Contraindications: Hypersensitivity, 1st
trimester pregnancy, caution with neonates, myasthenia gravis
Dose: 0.1mg/kg IV; maintenance 0.015-0.1mg/kg infusion
Onset of Action: 30-45 seconds
Duration of Action: 30-60 minutes
Atracurium
Non-depolarizing neuromuscular blocking agent
Indications: RSI – paralytic agent
Effects: Binds competitively at ACh sites, antagonising action of Ach, resulting in paralysis

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Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus
arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure,
increased ICP
Contraindications: Hypersensitivity, impaired hepatic/respiratory function, severe obesity, caution with
asthmatics
Dose: 0.4-0.5mg/kg IV
Onset of Action: 2-3 minutes
Duration of Action: 30-40 minutes
Bibliography
1. Bledsoe B. & Clayden D. (2012) Prehospital Emergency Pharmacology – 7th
Edition. Boston, MA: Pearson
2. Pollak A. (ed.) (2011) Critical Care Transport. Burlington, MA: Jones & Bartlett
3. Derr P. & Criddle L. (2011) Emergency & Critical Care Pocket Guide. Burlington, MA: Jones & Bartlett