You are working in the resuscitation bay when EMS rolls in with a hypotensive, hypoxic, meekly responsive febrile patient. You are preparing to intubate and the nurse asks what medications you would like (note: everybody is looking at you). Blood pressure is 75/40. You pause briefly, an appropriate response, and consider your options for this hypotensive, likely septic patient.

[spacer height=”20px”]In addition to giving fluid boluses and push dose pressors, you must be selective regarding to your sedative/paralytic options, and most importantly, dosing. Why? Because sedative hypnotics can cause decreased cardiac output (recall CO = HR x SV) by three primary mechanisms: decreased chronotropy (HR), vasodilation causing decreased venous return (SV) and with some agents, decreased ionotropy (read: propofol).  As such, approximately 25% of patients experience hypotension after RSI and you want to minimize your impact.

[spacer height=”20px”]1. What to avoid:

[spacer height=”20px”]2. Your best bets: 
[spacer height=”20px”]Ketamine: 0.5 mg/kg
Etomidate:  0.15mg/kg (aka 10mg rather than 20mg; questionable side effect of adrenal insufficiency)
Fentanyl + Midazolam: 1-2mcg/kg + 0.15mg/kg
[spacer height=”20px”]The Gist: When in doubt, start by halving whatever medications are available but always draw up a full dose in case this amount is insufficient.
[spacer height=”20px”]3. What not to do:
[spacer height=”20px”]Do not confuse sedation reduction with paralytic reduction. You want to have the best shot of first pass success with these patients, plus medication onset will be prolonged, so experts recommend going up on your paralytic dosing.
[spacer height=”20px”]Rocuronium: 1.6mg/kg
Succinylcholine: 2mg/kg
[spacer height=”20px”]And next time make that pause even more brief!
[spacer height=”20px”]Sources:
Image taken from:
[spacer height=”20px”]Jabre, Patricia, et al. “Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial.” Lancet (London, England) 374.9686 (2009): 293-300.
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May 2024