This document provides information on commonly used agents for rapid sequence induction including pre-medication, sedative, and paralytic agents. It describes the class, indications, effects, side effects, contraindications, dosing, onset and duration of action for lidocaine, atropine, fentanyl, etomidate, midazolam, ketamine, propofol, succinylcholine, vecuronium, rocuronium, pancuronium, and atracurium which are often used for rapid sequence intubation.

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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