“Induction meds” + “Pain + Paralysis”

 

Induction agents (sedation)

• Ketamine 1–2 mg/kg

• Etomidate 0.3 mg/kg

• Propofol 1–2 mg/kg

Paralytics (NMBAs)

• Rocuronium 1.2 mg/kg (most common in ICU)

• Succinylcholine 1–1.5 mg/kg (very fast but more contraindications)

 

1. PRE-MEDICATION 

Used 2–3 minutes before induction based on patient condition.

Indication	Medication	Dose	Purpose
Pain control	Fentanyl	1–3 mcg/kg IV	Blunts sympathetic surge during laryngoscopy
ICP elevation / TBI	Lidocaine	1–1.5 mg/kg IV	Suppresses cough, lowers ICP (mixed evidence)
Bronchospasm / Status asthmaticus	Lidocaine	1–1.5 mg/kg IV	Blunts reflex bronchospasm
Sympathetic surge concern (aortic dissection, SAH)	Esmolol	0.5 mg/kg IV	Prevents tachycardia/HTN surge
Pediatric bradycardia risk	Atropine	0.02 mg/kg IV (min 0.1 mg)	Prevents bradycardia with succinylcholine

Most common real-world pre-med:
✔ Fentanyl 100 mcg IV (adults)

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2. INDUCTION AGENTS (SEDATION)

Given immediately before the paralytic.

Medication	Dose	Onset	Pros	Cons
Etomidate	0.3 mg/kg IV	30–60 sec	Hemodynamically stable	Can suppress cortisol
Ketamine	1–2 mg/kg IV	30–60 sec	Maintains BP, bronchodilator, analgesia	↑ secretions, hallucinations
Propofol	1–2 mg/kg IV	15–45 sec	Fast, good for seizures	Hypotension, avoid in shock
Midazolam	0.1–0.3 mg/kg IV	1–2 min	Good for seizures	Slower onset, hypotension

Most common ICU choices:
✔ Ketamine (if shock or bronchodilation needed)
✔ Etomidate (if hemodynamically unstable but not profoundly shocky)

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3. PARALYTICS (NMBAs)

Given immediately after induction.

Medication	Dose	Onset	Duration	Notes
Rocuronium	1.2 mg/kg IV (RSI dose)	45–60 sec	45–70 min	Preferred in ICU; longer duration
Succinylcholine	1–1.5 mg/kg IV	45 sec	5–10 min	Avoid in hyperK, ESRD, burns, neuromuscular disease
Vecuronium	0.1 mg/kg IV	2–3 min	45 min	Rarely first-line for RSI

Most common ICU paralytic:
✔ Rocuronium 1.2 mg/kg

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4. POST-INTUBATION MANAGEMENT

A. Sedation (start immediately!)

• Propofol 5–10 mcg/kg/min, titrate

• Fentanyl 25–50 mcg/hr, titrate

• Dexmedetomidine if light sedation desired

B. Analgesia

• Fentanyl first-line

C. Check

• Tube depth (21–23 cm at teeth)

• Breath sounds bilaterally

• ETCO₂ confirmation

• CXR for tube placement

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5. THE “RSI CHECKLIST” (Quick Memory Tool)

P – Preparation
P – Pre-oxygenation
P – Pretreatment (optional)
P – Paralysis (with induction)
P – Positioning
P – Placement
P – Post-intubation management

• Preparation

• Pre-oxygenation (3–5 minutes of 100% O₂, or 8 vital capacity breaths)

• Pre-treatment (optional meds like fentanyl, lidocaine)

• Paralysis with Induction (give sedative → paralytic immediately)

• Positioning

• Placement (laryngoscopy + ETT placement)

• Post-intubation management