The Goal of RSI
Rapid sequence intubation uses a sedative or induction agent followed by a paralytic to create ideal intubation conditions in a patient who is not in arrest. It is a paramedic-level skill, but the NREMT may test the concepts of pharmacology and patient preparation. The key is to protect the airway while minimizing physiologic stress.
Induction Agents and Paralytics
Common induction agents include etomidate, ketamine, and midazolam. Etomidate is favored for hemodynamic stability, while ketamine is useful in asthma because of its bronchodilating properties. Succinylcholine is a depolarizing paralytic with a short duration, and rocuronium is a nondepolarizing option with a longer duration.
Critical Reminders
Paralysis without sedation is inhumane, because the patient remains awake but cannot move. Always have a backup airway plan, continuous monitoring, and post-intubation sedation ready. Succinylcholine is contraindicated in patients with hyperkalemia risk such as crush injuries or burns older than 24 hours.