Airway management

Rapid sequence induction: drugs and technique

Reviewed Nov 2026·6 references
New· views rounded down, updated weekly

Use reduced-dose, haemodynamically safer induction (ketamine or etomidate in shock), full-dose rocuronium or succinylcholine, a video laryngoscope with bougie or stylet, and confirm with waveform capnography.

At the bedside

Timed steps
  1. 1

    Final check

    -3 min

    Monitoring (SpO2, ECG, BP every 1-2 min or arterial line), capnography attached, suction on, drugs labelled, vasopressor ready.

  2. 2

    Induction agent

    0 s

    Shock: ketamine 0.5-1 mg/kg or etomidate 0.15-0.2 mg/kg. Stable: propofol 1-1.5 mg/kg or ketamine 1-2 mg/kg.

  3. 3

    Paralytic immediately after

    0 s

    Rocuronium 1.2 mg/kg or succinylcholine 1.5 mg/kg (actual body weight).

  4. 4

    Laryngoscopy

    45-60 s

    Video laryngoscope first-line (DEVICE); bougie or stylet for every attempt. Cricoid pressure optional; release if it worsens the view.

  5. 5

    Waveform capnography

    Confirm

    Sustained ETCO2 waveform over ≥ 5 breaths. 'No trace = wrong place' (except in arrest with very poor CPR).

  6. 6

    Post-induction hypotension

    0-30 min

    Expect it: noradrenaline titration, small fluid bolus if responsive (routine fluid bolus did not prevent collapse: PREPARE II). Start sedation and analgesia promptly.

Induction (shock, asthma, sepsis)

Ketamine

IV
Dose
1-2 mg/kg (0.5-1 mg/kg in shock)
Range
0.5–2 mg/kg
Preparation
200 mg in 20 mL = 10 mg/mL
Worked example
70 kg in shock: 0.75 mg/kg ≈ 50 mg = 5 mL of 10 mg/mL

Induction (haemodynamic stability)

Etomidate

IV
Dose
0.2-0.3 mg/kg (0.15-0.2 mg/kg in shock)
Range
0.15–0.3 mg/kg
Preparation
Undiluted 2 mg/mL
Worked example
70 kg × 0.2 = 14 mg = 7 mL

Induction in stable patients

Propofol

IV
Dose
1-2 mg/kg; 0.5-1 mg/kg if elderly or borderline BP
Range
0.5–2 mg/kg
Preparation
Undiluted 10 mg/mL
Worked example
70 kg × 1.5 = 105 mg ≈ 10.5 mL

RSI paralysis

Rocuronium

IV
Dose
1.2 mg/kg actual body weight
Preparation
Undiluted 10 mg/mL
Worked example
70 kg × 1.2 = 84 mg ≈ 8.4 mL (round to 90-100 mg)

RSI paralysis (no contraindication)

Succinylcholine (suxamethonium)

IV
Dose
1.5 mg/kg actual body weight
Preparation
Undiluted 50 mg/mL
Worked example
70 kg × 1.5 = 105 mg ≈ 2.1 mL

Blunt pressor response (ICP, dissection, ACS)

Fentanyl

IV
Dose
1-3 mcg/kg 3 min before induction; omit in shock
Preparation
Undiluted 50 mcg/mL
Worked example
70 kg × 2 = 140 mcg ≈ 2.8 mL

Induction agents compared

AgentDoseHaemodynamicsBest forWatch out
Ketamine1-2 mg/kg (0.5-1 in shock)Usually maintains BP; can fall in catecholamine depletionShock, asthma, sepsisTachycardia, hypertension, secretions
Etomidate0.2-0.3 mg/kgMost stableShock, cardiac diseaseAdrenal suppression (single dose), myoclonus
Propofol1-2 mg/kgHypotension commonStable patients, status epilepticusShock, elderly
Midazolam0.05-0.1 mg/kg (slow onset)HypotensionWhen others unavailableSlow onset, poor intubating conditions
Red flag · call your senior now
No capnography trace: assume oesophageal intubation; remove the tube unless you can see it through the cords on VL.
Red flag
Succinylcholine with hyperkalaemia, crush, burns > 24 h, denervation or prolonged immobility: risk of fatal hyperkalaemia.
Red flag
SBP < 65 mmHg after induction: noradrenaline bolus/infusion now, check for tension pneumothorax or auto-PEEP.
Pitfall
Under-dosing the paralytic (worse intubating conditions).
Pitfall
Hyperventilating with the bag after intubation (auto-PEEP, hypotension).
Pitfall
Forgetting post-intubation sedation after short-acting induction with long-acting rocuronium (awareness).
Pearl
With rocuronium 1.2 mg/kg, sugammadex 16 mg/kg can reverse within ~3 min, but in the ICU waking up is rarely a real rescue plan.

Calculators for this topic

Predicted (ideal) body weight

ARDSNet predicted body weight from height and sex. Use for tidal volume, not for most drug doses.

Shock index

Heart rate ÷ systolic BP.

References

  1. 1

    Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient. Crit Care Med. 2023;51(10):1411-1430

  2. 2

    Casey JD, Seitz KP, Driver BE, et al. Ketamine or etomidate for tracheal intubation of critically ill adults (RSI trial). N Engl J Med. 2026;394(16):1608-1620 (online Dec 2025)

  3. 3

    Prekker ME, Driver BE, Trent SA, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults (DEVICE). N Engl J Med. 2023;389(5):418-429

  4. 4

    Driver BE, Semler MW, Self WH, et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients (BOUGIE). JAMA. 2021;326(24):2488-2497

  5. 5

    Russell DW, Casey JD, Gibbs KW, et al. Effect of fluid bolus administration on cardiovascular collapse among critically ill patients undergoing tracheal intubation (PREPARE II). JAMA. 2022;328(3):270-279

  6. 6

    Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323-352

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