Pretreatment drugs for Rapid Sequence Intubation (RSI)

Reviewed and revised 8 July 2014

OVERVIEW

Traditionally there are four options for pretreatment for RSI:

atropine 20 mcg/kg IV — prevent bradycardia in children
lignocaine 1.5mg/kg IV — sympatholytic, neuroprotection in head injury; decrease airway reactivity in asthma
fentanyl 2-3 mcg/kg IV — sympatholytic, neuroprotection in head injury and vascular emergencies (e.g. myocardial ischaemmia, aortic dissection, subarachnoid haemorrhage)
defasciculating dose of a non-depolarising neuromuscular blocker (e.g. rocuronium 0.1 mg/kg IV or vecuronium 0.01 mg/kg IV) — prevents fasciculations from suxamethonium (e.g. TBI)

Other agents suggested as pretreatment for rapid sequence induction:

EVIDENCE

There is little evidence that any of these are beneficial clinically
They should not be a routine part of clinical practice but may be considered in selected patients by skilled practitioners

Journal articles

Kovacs G, Macquarrie K, Campbell S. Pretreatment in rapid sequence intubation: Indicated or contraindicated? CJEM. 2006 Jul;8(4):243; author reply 243-4. PubMed PMID: 17324300. [Free Full Text]
Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001 Sep;18(5):373-5. Review. PubMed PMID: 11559609; PubMed Central PMCID: PMC1725690.
Butler J, Jackson R. Best evidence topic report. Lignocaine as a pretreatment to rapid sequence intubation in patients with status asthmaticus. Emerg Med J. 2005 Oct;22(10):732. Review. PubMed PMID: 16189042; PubMed Central PMCID: PMC1726553.

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