An induction agent (e.g. propofol) induces a state of immediate unresponsiveness. This is then followed by the administration of a neuromuscular blocking agent to induce paralysis. The combination of drugs ceases spontaneous ventilation in the patient and allows for better view of the vocal cords. RSI is useful in patients with an intact gag reflex, a full stomach and a life threatening injury or illness requiring immediate airway control.

There are considerable variations in medications used for induction and paralysis. In the UK, propofol and ketamine remain the two most commonly used induction agents. There is now a shift of use of paralytic agent, from suxamethonium to rocuronium. In a recent analysis of 4275 intubations performed in the ED (USA), suxamethonium and rocuronium exhibited no differences in first-pass success (87.0% versus 87.5%) or adverse events (14.7% versus 14.8%) (April MD et al). This study only examined patients receiving either suxamethonium or rocuronium.

The most common induction agents used are:

Drug How to make up Final concentration
Propofol 1% Neat – into 20ml syringe 10mg/ml
Ketamine 500mg/10ml Neat – into 10ml syringe 50mg/ml
Thiopentone 500mg vial Add 20ml water into 20ml syringe 25mg/ml
Etomidate 20mg/10ml Neat – into 10ml syringe 2mg/ml

The most common paralysing agents used are:

Drug How to make up  Final concentration
Suxamethonium 50mg/ml Neat – 1 ampoule into 2ml syringe 50mg/ml
Rocuronium 50mg/5ml Neat – 2 ampoules into 10ml syringe 10mg/ml
Atracurium 50mg/5ml Neat – 2 ampoules into 10ml syringe 10mg/ml
Vecuronium 10 mg Add 5ml water into 5ml syringe 2mg/ml
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