Mastering RSI in the ED: Sedate, Paralyze, Tube 

-Case-
You’re managing a 56-year-old man in respiratory distress from severe pneumonia. He’s working hard to breathe, oxygen sats are falling despite noninvasive support, and he’s becoming confused. It’s time to intubate. Your nurse looks at you: “What meds do you want for RSI?” It’s your time to shine…

-Overview-
RSI is the cornerstone of emergency airway management. It involves simultaneous administration of a sedative (induction agent) and a neuromuscular blocker to achieve rapid unconsciousness and paralysis for safe intubation.

RSI Prep:

  1. Prepare: equipment (ET tube, blade, etc.), suction, monitoring, backup airway plan
  2. Preoxygenate: 100% FiO₂ via non-rebreather or BVM with PEEP
  3. Paralyze and Induce: administer sedative and paralytic
  4. Pass the Tube: intubate!
  5. Post-Intubation Care: confirm placement, secure tube, initiate sedation

-Induction Agents-

-Paralytics-

-Fast Facts-

  • In hypotensive or shocked patients, ketamine is preferred
  • Suspected elevated ICP or head injury? Etomidate or ketamine are your friends!
  • Contraindications to succinylcholine? Use rocuronium!
  • Anticipated difficult airway? Consider delayed sequence intubation or awake approach

RSI is a critical skill for emergency providers, and getting the meds right can be the difference between a smooth airway and disaster. Whether it’s etomidate for the crashing trauma patient or ketamine for the hypotensive asthmatic, the choice must be quick and precise. Know your drugs, anticipate complications, and prepare for what comes next – because in airway management, there’s no time for guesswork!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

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Tamir Zitelny, MD

-References-

  1. Walls RM, Murphy MF. Manual of Emergency Airway Management. 5th ed. Wolters Kluwer; 2018.
  2. Reiter PD, Strother CG. Rapid sequence intubation. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK470403/
  3. Reichman EF, Simon RR. Emergency Medicine Procedures. 2nd ed. McGraw Hill; 2013.
  4. Cash RE, Crowe RP, Panchal AR, et al. Duration of paralysis after rapid sequence intubation with succinylcholine versus rocuronium in the emergency department. Acad Emerg Med. 2021;28(4):407-414. doi:10.1111/acem.14197
  5. Green SM, Roback MG, Krauss B, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461. doi:10.1016/j.annemergmed.2010.11.030
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