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Rapid Sequence Intubation drug dosing calculator with induction agents and paralytics
RSI is a high-risk procedure requiring trained personnel and proper preparation. This calculator is for reference only. Always follow institutional protocols and have backup airway plans ready.
Range: 0.2-0.4 mg/kg
Onset: 15-45 seconds
Duration: 5-15 minutes
Range: 0.6-1.2 mg/kg
Onset: 60-90 seconds (high dose)
Duration: 45-60 minutes
Induction: Most hemodynamically stable. May cause adrenal suppression. First choice for hypotensive patients.
Paralytic: Non-depolarizing. Use high dose (1.2 mg/kg) for RSI. Reversible with sugammadex. Safe alternative to succinylcholine.
21.0 mg (0.2-0.4 mg/kg)
Most hemodynamically stable. May cause adrenal suppression. First choice for hypotensive patients.
105.0 mg (1-2 mg/kg)
Maintains BP and respiratory drive. Use for asthma, bronchospasm, hypotension. May increase ICP.
105.0 mg (1-2.5 mg/kg)
Causes hypotension. Reduce dose in elderly/hypotensive. Anti-seizure properties. Avoid in shock.
14.0 mg (0.2-0.3 mg/kg)
Slower onset. Causes hypotension. Amnesia. Use with caution in hemodynamically unstable patients.
105 mg (1-1.5 mg/kg)
Onset: 45-60 seconds
Fastest onset. Depolarizing agent. CI: hyperkalemia, malignant hyperthermia, burns >24hr, neuromuscular disease.
84 mg (0.6-1.2 mg/kg)
Onset: 60-90 seconds (high dose)
Non-depolarizing. Use high dose (1.2 mg/kg) for RSI. Reversible with sugammadex. Safe alternative to succinylcholine.
7.0 mg (0.08-0.1 mg/kg)
Onset: 90-120 seconds
Non-depolarizing. Slower onset than rocuronium. Minimal cardiovascular effects. Less commonly used for RSI.
105.0 mg
Attenuate ICP rise (controversial)
Give 3 minutes before
210 mcg
Blunt sympathetic response
Give 3 minutes before
Peds: 1.40 mg
Adult: 0.5 mg
Prevent bradycardia (pediatrics, repeat succinylcholine)
Give 1-2 minutes before
LEMON assessment:
Look externally (facial trauma, obesity, small jaw)
Evaluate 3-3-2 rule (mouth opening, hyoid-mental distance)
Mallampati classification
Obstruction (tumor, infection, foreign body)
Neck mobility (C-spine injury, arthritis)
If unable to intubate after 3 attempts or desaturation, declare failed airway. Options: (1) Supraglottic airway (LMA/i-gel), (2) Bag-mask ventilation, (3) Surgical airway (cricothyrotomy). Cannot intubate, cannot oxygenate (CICO) requires immediate surgical airway.
Obesity: Ramping, apneic oxygenation crucial
Elderly: Reduce induction dose by 30-50%
Pregnant: Rapid desaturation, use smaller ET tube
C-spine injury: Maintain inline stabilization
Pediatric: Larger head, higher O2 consumption
After successful intubation, start continuous sedation: Propofol 25-75 mcg/kg/min OR Midazolam 0.05-0.2 mg/kg/hr PLUS Fentanyl 0.5-2 mcg/kg/hr. Consider paralytic infusion if ventilator dyssynchrony: Rocuronium 10-12 mcg/kg/min OR Vecuronium 1-2 mcg/kg/min.
RSI uses rapid administration of induction agent followed immediately by paralytic to create optimal intubating conditions while minimizing aspiration risk. No bag-mask ventilation is performed between drug administration and intubation (to avoid gastric insufflation). Standard intubation may involve gradual sedation and assisted ventilation.
Etomidate is the first choice for most patients due to hemodynamic stability. Use ketamine for hypotensive patients, asthma/bronchospasm, or preserving respiratory drive. Propofol is good for normotensive patients and those with seizures, but avoid in shock. Consider patient's blood pressure, cardiac status, and underlying conditions.
Absolute contraindications: Known malignant hyperthermia, acute hyperkalemia, chronic neuromuscular disease (myasthenia gravis, muscular dystrophy). Relative contraindications: Burns >24 hours old, crush injuries >24 hours, denervation injuries >72 hours (stroke, spinal cord injury), severe intra-abdominal infection. These conditions risk life-threatening hyperkalemia.
Cricoid pressure is controversial. Previously recommended to prevent aspiration, recent evidence shows it may not be effective and can impede intubation. Current practice varies: some use it routinely, others only for high aspiration risk, and some have abandoned it. If used, release immediately if it interferes with intubation or ventilation.
After 3 intubation attempts or critical desaturation, declare failed airway. First, optimize oxygenation with bag-mask or supraglottic airway (LMA/i-gel). If cannot intubate but can oxygenate, wake patient up or perform awake fiberoptic intubation. If cannot intubate, cannot oxygenate (CICO), perform emergency cricothyrotomy immediately.
Hypotension (most common, especially with propofol), hypoxemia from apnea or failed intubation, aspiration, esophageal intubation, dental trauma, cardiovascular collapse, laryngospasm, and bronchospasm. Meticulous preparation, appropriate drug selection, and having backup plans ready minimize complications. Always confirm tube placement with waveform capnography.
This RSI drug calculator is for educational and reference purposes only. It is designed for use by healthcare professionals trained in airway management and rapid sequence intubation. RSI is a high-risk procedure that requires proper training, preparation, and backup plans. This tool does not replace clinical judgment, formal airway training, or institutional protocols. Always have difficult airway equipment and rescue plans ready. Emergent airway management should only be performed by qualified personnel.