Rapid Sequence Intubation

Author: Demian Szyld, MD
Updated: 7/16/2010

Rapid Sequence Intubation (RSI)


Patients without a pulse do not require medications to facilitate intubation.

Maximize your chances for first-pass success with:

  1. Preparation: Room, airway equipment, suction, monitor, IV access, personnel
  2. Pre-oxygenation: NRB mask for spontaneously breathing patient, ventilate if hypoxic
  3. Positioning: Ear above sternum or ramp
  4. Plan A: Share your laryngoscopy and intubation plan (bougie?, video?)
  5. Plan B: Share your rescue ventilation and rescue intubation plan (LMA?, cric kit?)
  6. Paralysis: Optimize laryngoscopic view with muscle relaxants
  7. Post-intubation: Secure and confirm tube placement, sedation and vent orders

Avoid paralysis without sedation.

Avoid paralysis when difficulty laryngoscopy is anticipated. Consider awake intubation strategy, alternatively.

  1. Distortion (of upper or lower airway ie: trauma, anaphylaxis)
  2. Disproportion (small jaw, large tongue)
  3. Dysmobility (neck stiffness, c-collar, rheumatoid arthritis)
  4. Dentition (large teeth = small mouth opening)



Medication Weight-based dose 80 kg / 180 lbs dose Indications
Lidocaine 1.5 mg/kg 120 mg Head, lung
Fentanyl 3 mcg/kg 250 mcg Head, heart


Medication Weight-based dose 80 kg / 180 lbs dose Indications
Etomidate 0.3 mg/kg 24 mg
Propofol 1.5 mg/kg 120 mg
Thiopental 3 mg/kg 250 mg
Ketamine IV 1.5 mg/kg 120 mg Asthma
Ketamine IM 3.0 mg/kg 240 mg No IV access
Midazolam 0.3 mg/kg 24 mg


Medication Weight-based dose 80 kg / 180 lbs dose Indications
Succinylcholine 1.5 mg/kg 120 mg
Rocuronium 1.0 mg/kg 80 mg
Vecuronium 0.2mg/kg 16 mg


  • Airway Cam Pocket Guide to Intubation, 2nd Edition [Source]
  • “The Airway Card”, The Airway Course [Source]