Rapid Sequence Intubation (RSI)

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All patients who respond to noxious stimuli should be sedated and paralyzed prior to endotracheal intubation. In RSI, the induction agent is dosed to provide a deep level of sedation (induction) and is rapidly followed by a paralytic agent which is necessary to both allow for optimal intubating conditions and improve the chance of a successful intubation. The specific induction and paralytic agents should be chosen based on the clinical scenario, taking into consideration pharmacokinetics, pharmacodynamics, indications, contraindications, and side effects which will be discussed in this module.

After successful intubation, post-intubation management should begin with implementing a plan for analgesia and sedation, when indicated. Addressing analgesia and sedation improves patient comfort and decreases the sympathetic response to the endotracheal tube.1 Details of post-intubation management will be addressed in a separate module.

Learning Objectives

  1. Describe the medications that can be used for induction prior to RSI.
  2. Compare the pharmacologic properties of succinylcholine and rocuronium including contraindications for succinylcholine.
  3. Based on a simulated patient case, select the optimal induction and paralytic regimen for a patient requiring endotracheal intubation.
Chris Edwards, PharmD, BCPSEmergency Medicine Pharmacist, University of Arizona Medical Center@emergencypharm
Rob Pugliese, PharmD, BCPSEmergency Medicine Pharmacist, Thomas Jefferson University@theEDpharmacist
Liz Temin, MD, MPHAssistant Professor of Emergency Medicine, Harvard Medical School
Course Editor: Mike O’Brien, PharmDEmergency Medicine Pharmacist, Massachusetts General Hospital@mikeEMpharmD
Course Editor: Sarah Grzybinski, PA-CEmergency Medicine Physician’s Assistant, Massachusetts General Hospital
Instructional Design Editor: Emily Small, PharmDEmergency Medicine Pharmacist@pharmdEMily
Lead Editor: Bryan Hayes, PharmD, FAACT, FASHPClinical Pharmacy Manager, Massachusetts General Hospital@PharmERToxGuy


  1. Walls RM. Airway. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Saunders/Elsevier; 2014

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