Pharmacotherapy optimization for rapid sequence intubation in the emergency department

Am J Emerg Med. 2023 Aug:70:19-29. doi: 10.1016/j.ajem.2023.05.004. Epub 2023 May 10.


Purpose: Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods.

Summary: There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use.

Areas for future research: The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Keywords: Induction; Neuromuscular blocking agent; Pharmacotherapy; Rapid sequence intubation.

Publication types

  • Review

MeSH terms

  • Emergency Service, Hospital
  • Etomidate* / therapeutic use
  • Humans
  • Hypnotics and Sedatives / therapeutic use
  • Intubation, Intratracheal / methods
  • Ketamine* / therapeutic use
  • Neuromuscular Blocking Agents* / therapeutic use
  • Rapid Sequence Induction and Intubation
  • Retrospective Studies
  • Rocuronium
  • Succinylcholine


  • Succinylcholine
  • Etomidate
  • Rocuronium
  • Ketamine
  • Hypnotics and Sedatives
  • Neuromuscular Blocking Agents