Rapid-sequence intubation and the role of the emergency department pharmacist

The pharmacology, pharmacokinetics, safety, and dosing of medications used during the pretreatment and paralysis with induction steps of rapid-sequence intubation (RSI) and the role of the pharmacist in RSI are reviewed.

RSI is a process involving the administration of a sedative induction agent and a paralytic agent to facilitate endotracheal intubation. This is a procedure in which the emergency department (ED) pharmacist can play an integral role, especially in the steps of pretreatment, paralysis with induction, and postintubation management. The pretreatment phase occurs three minutes before administration of induction and neuromuscular blockers. The purpose of pretreatment is to attenuate the pathophysiologic response to laryngoscopy and intubation. Three minutes after the pre-treatment agents have been administered, paralysis with induction will begin. The purpose of induction is to produce a state of general anesthesia, allowing for the administration of paralytics and facilitation of ideal intubating conditions. It is advisable for the ED pharmacist to be familiar with the steps and medications involved with RSI so that appropriate interventions may be made, facilitating both the successful intubation and the safety of the patient. The relative chaos that may occur during emergent RSI requires the ED pharmacist to have a clearly defined primary plan as well as contingency plans to deal with potential complications. Commonly used medications during intubation include lidocaine, fentanyl, etomidate, midazolam, thiopental, ketamine, succinylcholine, and rocuronium.

The selection of an appropriate sedative and neuromuscular blocker during the pretreatment and paralysis with induction steps of RSI can be facilitated by an ED pharmacist.