Rapid Sequence Intubation (RSI) is the gold-standard emergency airway management technique that combines a sedative-hypnotic agent with a rapid-onset neuromuscular blocking agent (NMBA) to achieve loss of consciousness and complete muscle paralysis simultaneously, allowing immediate tracheal intubation with minimal risk of pulmonary aspiration. RSI is indicated whenever a patient requires immediate definitive airway protection and is presumed to have a full stomach. The technique was developed to minimise the window between loss of protective airway reflexes and placement of a cuffed endotracheal tube. Standard RSI includes pre-oxygenation for at least 3 minutes with 100% FiO2, optional pretreatment agents (fentanyl 3 mcg/kg IV to blunt intubating conditions, especially in head injury), simultaneous administration of the induction agent and NMBA, application of cricoid pressure (Sellick manoeuvre, though increasingly debated), and laryngoscopy without bag-mask ventilation during the apnoeic interval. Ketamine (1–2 mg/kg IV) is the preferred induction agent in haemodynamically unstable or asthmatic patients due to its sympathomimetic and bronchodilatory properties. Propofol (1.5–2 mg/kg IV) is preferred in haemodynamically stable patients with raised intracranial pressure due to its ICP-lowering effect. Etomidate (0.3 mg/kg IV) is used where haemodynamic stability is critical but adrenal suppression concerns exist. Succinylcholine (1.5 mg/kg IV) provides the fastest onset (45–60 seconds) and shortest duration (10–15 minutes) of paralysis. Rocuronium (1.2 mg/kg IV) is the preferred alternative when succinylcholine is contraindicated, with onset at 60–90 seconds; it can be reversed with sugammadex 16 mg/kg.
Ketamine dose = 1–2 mg/kg IV; Propofol dose = 1.5–2 mg/kg IV; Succinylcholine dose = 1.5 mg/kg IV; Rocuronium dose = 1.2 mg/kg IV; Fentanyl pretreatment = 3 mcg/kg IV
- 1Step 1 — Preparation: Assemble equipment (laryngoscope, ETT, suction, bag-mask, difficult airway trolley), draw up all drugs, confirm IV access, attach monitoring (SpO2, ECG, BP, EtCO2).
- 2Step 2 — Pre-oxygenation: Deliver 100% O2 via tight-fitting non-rebreather mask or BVM for at least 3 minutes (8 vital-capacity breaths accepted if time-critical) to maximise oxygen reserve.
- 3Step 3 — Pretreatment (optional): Give fentanyl 3 mcg/kg IV 3 minutes before induction to blunt the sympathetic response to laryngoscopy, particularly in traumatic brain injury.
- 4Step 4 — Induction agent: Administer the chosen sedative (ketamine 1–2 mg/kg, propofol 1.5–2 mg/kg, or etomidate 0.3 mg/kg) as a rapid IV bolus.
- 5Step 5 — Neuromuscular blockade: Immediately follow with succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV; await complete fasciculations (succinylcholine) or 60 seconds (rocuronium).
- 6Step 6 — Laryngoscopy and intubation: With the patient paralysed and sedated, perform direct or video-assisted laryngoscopy and place a cuffed ETT; inflate cuff and confirm position with waveform capnography and bilateral auscultation.
- 7Step 7 — Post-intubation management: Secure the tube, initiate ventilator settings, obtain post-intubation CXR, and begin ongoing sedation and analgesia to maintain patient comfort.
Ketamine chosen for its ICP-neutral profile at standard doses; succinylcholine for fastest onset
Fentanyl 3 mcg/kg × 70 = 210 mcg; Ketamine 1–2 mg/kg × 70 = 70–140 mg; Succinylcholine 1.5 mg/kg × 70 = 105 mg. Rocuronium 1.2 × 70 = 84 mg if sux contraindicated.
Ketamine's sympathomimetic properties support blood pressure during induction
Propofol causes significant vasodilation and is avoided in hypotensive patients. Ketamine 1–2 mg/kg × 80 = 80–160 mg. Succinylcholine 1.5 × 80 = 120 mg.
Succinylcholine causes life-threatening K+ release in denervation/crush injuries >24 h old
Rocuronium 1.2 mg/kg × 60 = 72 mg. Sugammadex reversal dose = 16 mg/kg × 60 = 960 mg.
Ketamine is the induction agent of choice in bronchospasm due to bronchodilatory effect
Ketamine 1–2 mg/kg × 90 = 90–180 mg; Sux 1.5 × 90 = 135 mg. Avoid propofol which can trigger bronchospasm at induction.
Emergency department management of patients with depressed consciousness, respiratory failure, or airway compromise, representing an important application area for the Rsi Adult Dose in professional and analytical contexts where accurate rsi adult dose calculations directly support informed decision-making, strategic planning, and performance optimization
Pre-hospital critical care intubation by paramedics and HEMS physicians in trauma and medical emergencies, representing an important application area for the Rsi Adult Dose in professional and analytical contexts where accurate rsi adult dose calculations directly support informed decision-making, strategic planning, and performance optimization
Operating theatre rapid sequence for patients at risk of aspiration (full stomach, pregnancy, bowel obstruction), representing an important application area for the Rsi Adult Dose in professional and analytical contexts where accurate rsi adult dose calculations directly support informed decision-making, strategic planning, and performance optimization
Intensive care unit intubation for deteriorating patients requiring mechanical ventilation, representing an important application area for the Rsi Adult Dose in professional and analytical contexts where accurate rsi adult dose calculations directly support informed decision-making, strategic planning, and performance optimization
Inter-hospital transfer preparation for patients who need a secured airway for safe transport, representing an important application area for the Rsi Adult Dose in professional and analytical contexts where accurate rsi adult dose calculations directly support informed decision-making, strategic planning, and performance optimization
Traumatic Brain Injury
In the Rsi Adult Dose, this scenario requires additional caution when interpreting rsi adult dose results. The standard formula may not fully account for all factors present in this edge case, and supplementary analysis or expert consultation may be warranted. Professional best practice involves documenting assumptions, running sensitivity analyses, and cross-referencing results with alternative methods when rsi adult dose calculations fall into non-standard territory.
Haemodynamic Instability / Shock
In the Rsi Adult Dose, this scenario requires additional caution when interpreting rsi adult dose results. The standard formula may not fully account for all factors present in this edge case, and supplementary analysis or expert consultation may be warranted. Professional best practice involves documenting assumptions, running sensitivity analyses, and cross-referencing results with alternative methods when rsi adult dose calculations fall into non-standard territory.
Extremely large or small input values in the Rsi Adult Dose may push rsi adult
Extremely large or small input values in the Rsi Adult Dose may push rsi adult dose calculations beyond typical operating ranges. While mathematically valid, results from extreme inputs may not reflect realistic rsi adult dose scenarios and should be interpreted cautiously. In professional rsi adult dose settings, extreme values often indicate measurement errors, unusual conditions, or edge cases meriting additional analysis. Use sensitivity analysis to understand how results change across plausible input ranges rather than relying on single extreme-case calculations.
Pregnancy
In the Rsi Adult Dose, this scenario requires additional caution when interpreting rsi adult dose results. The standard formula may not fully account for all factors present in this edge case, and supplementary analysis or expert consultation may be warranted. Professional best practice involves documenting assumptions, running sensitivity analyses, and cross-referencing results with alternative methods when rsi adult dose calculations fall into non-standard territory.
Paediatric RSI
In the Rsi Adult Dose, this scenario requires additional caution when interpreting rsi adult dose results. The standard formula may not fully account for all factors present in this edge case, and supplementary analysis or expert consultation may be warranted. Professional best practice involves documenting assumptions, running sensitivity analyses, and cross-referencing results with alternative methods when rsi adult dose calculations fall into non-standard territory.
| Drug | Dose | Onset | Duration | Notes |
|---|---|---|---|---|
| Ketamine | 1–2 mg/kg IV | 45–60 sec | 10–20 min | 1st choice in hypotension/asthma |
| Propofol | 1.5–2 mg/kg IV | 30–45 sec | 5–10 min | Avoid in haemodynamic instability |
| Etomidate | 0.3 mg/kg IV | 30–60 sec | 10–15 min | Adrenal suppression risk |
| Succinylcholine | 1.5 mg/kg IV | 45–60 sec | 10–15 min | Depolarising; many CI |
| Rocuronium | 1.2 mg/kg IV | 60–90 sec | 45–70 min | Reversed by sugammadex |
| Fentanyl (pre-Rx) | 3 mcg/kg IV | ~3 min | 30–60 min | Blunts sympathetic response |
| Sugammadex (reversal) | 16 mg/kg IV | 3 min | Full reversal | For rocuronium CICV rescue |
What is the difference between RSI and standard intubation?
RSI uses simultaneous induction and paralysis without an intervening bag-mask ventilation phase, minimising the risk of gastric aspiration in patients assumed to have a full stomach. Standard intubation may include gradual sedation with ventilation between steps. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
When is succinylcholine contraindicated?
Succinylcholine is contraindicated in hyperkalaemia (K+ >5.5), burns or crush injuries >24–48 hours old, denervation injuries (paraplegia, stroke >72h), malignant hyperthermia susceptibility, myopathies (especially Duchenne), and personal/family history of pseudocholinesterase deficiency. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
Can rocuronium replace succinylcholine in RSI?
Yes. At 1.2 mg/kg, rocuronium achieves intubating conditions in 60–90 seconds, close to succinylcholine's 45–60 seconds. The key advantage is sugammadex 16 mg/kg can fully reverse rocuronium within 3 minutes if the intubation fails (cannot intubate, cannot oxygenate scenario). This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
Why is fentanyl given as a pretreatment?
Laryngoscopy triggers a powerful sympathetic response causing hypertension and tachycardia. In traumatic brain injury, this raises ICP dangerously. Fentanyl 3 mcg/kg IV given 3 minutes before induction blunts this response. It is not used universally as it may cause chest wall rigidity at high doses. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
What is the apnoeic oxygenation technique?
After paralysis, passive oxygen delivery via nasal cannula at 15 L/min during the apnoeic interval extends safe apnoea time by maintaining FRC oxygen saturation. This is recommended in critically ill patients who desaturate rapidly. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
What is the failed airway protocol?
If intubation fails after 2 attempts, declare a failed airway and call for help. Revert to bag-mask ventilation, consider supraglottic airway (LMA), and if oxygenation cannot be maintained, proceed to surgical cricothyrotomy. Never make more than 3 laryngoscopy attempts. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
What dose of ketamine is used in paediatric RSI?
Ketamine dosing in children is 1–2 mg/kg IV (same as adults). Succinylcholine dose in paediatrics is 2 mg/kg IV (higher than adults) to account for greater volume of distribution. Rocuronium remains 1.2 mg/kg. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
How do you confirm correct ETT placement?
The gold standard is waveform capnography (EtCO2 waveform over 6 ventilations). Additional confirmation includes bilateral equal breath sounds on auscultation, chest rise, absence of sounds over epigastrium, and condensation in the ETT. A post-intubation CXR confirms depth. This is particularly important in the context of rsi adult dose calculations, where accuracy directly impacts decision-making. Professionals across multiple industries rely on precise rsi adult dose computations to validate assumptions, optimize processes, and ensure compliance with applicable standards. Understanding the underlying methodology helps users interpret results correctly and identify when additional analysis may be warranted.
Pro Tip
The 'LOAD' mnemonic helps remember RSI pretreatment agents: Lidocaine (controversial, 1.5 mg/kg for bronchospasm), Opioid (fentanyl 3 mcg/kg for TBI/HTN), Atropine (children <5 yr pre-succinylcholine), Defasciculation (low-dose non-depolariser, rarely used). Always have your rescue plan — know your surgical airway approach before you start.
Did you know?
Succinylcholine was first synthesised in 1906 but not used clinically until 1951. It remains the fastest-acting neuromuscular blocker available 70 years later — no modern drug has beaten its 45-second onset to full paralysis in clinical use.