Rapid Sequence Intubation (RSI) & Its Drugs

Also known as Rapid sequence intubation · RSI · RSI drugs · Rapid sequence induction · Succinylcholine · Rocuronium · Sugammadex · Etomidate · Cricoid pressure · Sellick manoeuvre · First-pass success · Preoxygenation · Apnoeic oxygenation · THRIVE · HFNC · KETASED · Video laryngoscopy · Peri-intubation cardiac arrest · Sugammadex · INTUBE study · Peri-intubation hypotension

Rapid sequence intubation (RSI) is the standard for emergency airway control in the non-fasted, critically ill patient: preoxygenation, then an induction agent and a neuromuscular blocker in rapid succession. Classic teaching omits mask ventilation to limit gastric insufflation; DAS 2018 recommends a modified RSI, and PREVENT showed bag-mask between induction and laryngoscopy improved oxygenation without increasing aspiration. Induction agents are chosen to the haemodynamics (propofol/thiopentone in the stable; ketamine in shock/asthma; etomidate for neutrality, with the sepsis-adrenal controversy). Succinylcholine (fast, short, but hyperkalaemia and malignant hyperthermia) versus rocuronium (reversible with sugammadex). Confirm with waveform capnography. Cricoid pressure: insufficient evidence of aspiration benefit (Tessarolo); Jaber bundle still included it.

medium28 referencesUpdated 2 Sept 202641 min readSource-verified · Sept 2026

Checked against its sources on 3 Sept 2026

Practise this topic

8 MCQs

The one-line answer

Rapid sequence intubation secures the airway of the non-fasted critically ill patient by inducing and paralysing in rapid succession after thorough preoxygenation. Classic teaching omits mask ventilation between drugs; DAS 2018 recommends a modified RSI, and PREVENT found bag-mask between induction and laryngoscopy raised median lowest SpO2 (96 vs 93 per cent) and halved severe hypoxaemia without increasing aspiration. Preoxygenate (100 per cent O2 for 3 minutes of tidal-volume breathing, or 3-8 vital-capacity breaths), induce to the haemodynamics (ketamine in shock — in sepsis it is a safe, valuable alternative to etomidate), paralyse fully (rocuronium 1.2 mg/kg, reversible with sugammadex 16 mg/kg), pass the tube on the first attempt, and confirm with waveform capnography. The goal is first-pass success — repeated attempts cause the hypoxia, trauma and collapse that kill.^[3]^[6]^[18]^[19]^[11]^[7]

Meet the patient

A 66-year-old woman in septic shock — obtunded, hypoxic, with a full stomach — needs her airway secured now. Critically ill, obese and pregnant patients are exactly the groups in which preoxygenation fails fastest and the pressure falls the moment she is induced. RSI was designed for exactly this patient.^[3]

The exam question every RSI stem boils down to: what did you do in the minute before you paralysed her?^[4]

References28Show

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