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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Pretreatment drugs for Rapid Sequence Intubation (RSI)

Pretreatment drugs for Rapid Sequence Intubation (RSI)

by Chris Nickson, Last updated November 19, 2014

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:

  • remifentanil
  • gabapentin

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

References and Links

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.

FOAM and web resources

  • ACEP Now — Rapid Sequence Intubation Pharmacology (2010)

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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