ACLS - Rapid Sequence Induction 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Advanced Cardiac Life Support (ACLS): Rapid Sequence Induction and Intubation



1. Check all equipment (SOAP ME; see Pearls) [1, 2, 3, 4, 5, 6]

  • Test end tidal carbon dioxide (ETCO2) monitor

  • Ensure suction is functional

  • Child endotracheal tube (ETT) size = (age in years + 16)/4

  • Prepare rescue airway devices

2. Evaluate for difficult ventilation

  • Consider non–rapid sequence induction (RSI) approach (avoid paralysis) if there are risk factors for difficult ventilation

  • Consider expert consultation (anesthesia) if there is potential for a difficult airway, time permitting


1. Several options

  • Four vital capacity breaths over 30 seconds

  • Eight vital capacity breaths over 60 seconds

  • Five minutes of breathing 100% oxygen

2. Healthy patient reserve is about 6 minutes for desaturation to 90%; time is shorter in children, obese patients, and patients with underlying cardiopulmonary disease

3. If no anesthesia circuit (ICU/ED)

  • Use face mask (nonrebreather) with oxygen flow as high as possible

  • Bag-valve-mask (BVM) not ideal for preoxygenation

  • Consider noninvasive positive-pressure ventilation device (ie, bilevel positive airway pressure [BPAP]) if ventilation is inadequate

4. Consider apneic oxygenation

  • Nasal cannula with oxygen turned off prior to induction

  • Turn oxygen to 15 liters per minute (LPM) during laryngoscopy

Pretreatment (LOAD; see Pearls)

Premedication for increased intracranial pressure (ICP), head injury, bronchospasm, antibradycardia effect

  • Consider administering cerebral protection agent 2 minutes prior to intubation

  • Use of certain pretreatments is controversial

See the list below:

  1. Lidocaine 1.5 mg/kg IV: May blunt ICP rise and decrease bronchospasm

  2. Opiates (fentanyl 2-5 µg/kg IV): Can blunt response to intubation

  3. Anticholinergics: Atropine 0.02 mg/kg IV (min, 0.1 mg) for children; glycopyrrolate 0.005 mg/kg IV for children or 0.2-0.4 mg IV for adults

  4. Defasciculating dose of nondepolarizing muscle relaxant if succinylcholine planned

See the list below:

  • Give 1/10th the ED95 dose of nondepolarizing agent (ie, 1/20th intubating dose)

  • Succinylcholine dose should then be increased to 1.5 mg/kg if defasciculating agent used

Put to sleep

  1. Consider cricoid pressure and hold until placement is verified

  2. Do not ventilate until patient is intubated or reoxygenation is required

  3. Choose one induction agent

See the list below:

  • Etomidate 0.2-0.3 mg/kg IV

  • Ketamine 1-2 mg/kg IV

  • Methohexital 1-1.5 mg/kg IV

  • Propofol 1.5-2.5 mg/kg IV in adults

  • Propofol 2.5-3.5 mg/kg IV in children

  • Propofol 1-1.5 mg/kg IV in elderly patients

  • Thiopental 2-5 mg/kg IV


  1. Give along with induction agents; “timing” or “priming” techniques not recommended

  2. Choose one relaxant

See the list below:

  • Succinylcholine 1 mg/kg IV

  • Rocuronium 1.2 mg/kg IV

Pass the tube

  1. Intubate 45 seconds after paralytic; if oxygen saturation is inadequate, stop laryngoscopy and ventilate with bag-mask

  2. Tube depth is (12 + age in years/2), up to 20-22 cm in adult women and 22-24 cm in adult men

  3. Apply backward, upward, rightward pressure (BURP) during laryngoscopy, if needed

Placement verification

  1. Continuous capnography

  2. Auscultate chest, axillae, stomach

  3. Fogging in tube, chest radiography, etc

  4. Continue sedation as needed, especially if the patient has received a nondepolarizing relaxant


Mnemonic: SOAP ME, used for initial equipment check prior to administering medications

  • S: Suction, turned on and working

  • O: Oxygen, including backup supply

  • A: Airway equipment, including laryngoscopes, handles, endotracheal tubes, stylets, supraglottic airways

  • P: Pharmaceuticals, including induction agent, muscle relaxant, adjuvants, emergency medications

  • M: Monitors, with audible SpO2 tone and blood pressure at least every 5 minutes

  • E: Emergency equipment, including defibrillator and invasive airway equipment

Mnemonic: LOAD, options for cerebral protection agents during premedication

  • L: Lidocaine

  • O: Opioid, fentanyl

  • A: Anticholinergic, atropine or glycopyrrolate

  • D: Defasciculating, if succinylcholine planned


Induction of general anesthesia is typically required to obtain optimal conditions for endotracheal intubation. Muscle relaxants are then given after an induction agent to improve intubating conditions. Although any muscle relaxant can be used, succinylcholine or high-dose rocuronium is typically used for RSI, as they provide intubating conditions in the shortest time frame. Adjuncts can be used to improve intubating conditions and to reduce side effects (eg, intracranial hypertension) during laryngoscopy and intubation.

Succinylcholine is a depolarizing muscle relaxant with multiple side effects and contraindications. Contraindications to the use of succinylcholine include the following:

  • Known hyperkalemia

  • Massive burns >10% body surface area (BSA) (4 days - healed)

  • Massive crush injuries (4 days - healed)

  • Denervation/cerebrovascular accident (CVA) (4 days - 6 months)

  • Spinal cord injury (4 days - 6 months)

  • Neuromuscular disease (indefinite)

  • Intra-abdominal sepsis (5 days - resolution)

  • Increased ICP (may use with defasciculating agent first)

  • Personal or family history of malignant hyperthermia

Induction agents


  • Intravenous (IV)/intraosseous (IO) push: 0.2-0.3 mg/kg; maximum dose, 10 mg

  • Onset: 1-3 minutes

  • Duration: 20-40 minutes

  • Side effects: Hypotension

  • Notes: Hypotension exacerbated in combination with narcotics and barbiturates; no analgesic properties; excellent amnesia


  • IV/IO push: 0.2-0.4 mg/kg; limit to one dose

  • Onset: < 1 minute

  • Duration: 5-10 minutes

  • Side effects: Myoclonic activity; inhibition of cortisol synthesis for up to 12 hours

  • Notes: Ultrashort acting; no analgesic properties; decreases cerebral metabolic rate and ICP; generally maintains hemodynamic stability; avoid routine use in patients with suspected septic shock


  • IV/IO push: 1-2 mg/kg

  • Onset: < 1 minute

  • Duration: 10-20 minutes

  • Side effects: Hypertension, tachycardia; increased secretions and laryngospasm; emergency reactions and hallucinations

  • Notes: Dissociative anesthetic agent; limited respiratory depression; bronchodilator; may cause myocardial depression in catecholamine-depleted patients; use with caution in patients with potential or increased ICP


  • IV/IO push: 1-1.5 mg/kg

  • Onset: < 1 minute

  • Duration: 4-7 minutes

  • Side effects: Laryngospasm, bronchospasm, hiccups, twitching, seizures, pain on injection

  • Notes: Ultrashort-acting barbiturate; no analgesic properties


  • IV/IO push: 0.1-0.3 mg/kg; maximum dose 10 mg

  • Onset: 2-5 minutes

  • Duration: 15-30 minutes

  • Side effects: Hypotension

  • Notes: Hypotension exacerbated in combination with narcotics and barbiturates; no analgesic properties; excellent amnesia


  • IV/IO push: 1.5-2.5 mg/kg in adults, 2.5-3.5 mg/kg in children, 1-1.5 mg/kg in elderly patients

  • Onset: < 1 minute

  • Duration: 5-10 minutes

  • Side effects: Hypotension, especially in patients with inadequate intravascular volume; pain on infusion

  • Notes: No analgesic properties; very short duration of action; less airway reactivity than barbiturates; decreases cerebral metabolic rate and ICP; lidocaine may decrease infusion pain; not recommended in patients with egg/soy allergy


  • IV/IO push: 2-5 mg/kg

  • Onset: < 1 minute

  • Duration: 5-10 minutes

  • Side effects: Negative inotropic effects; hypotension

  • Notes: Ultrashort acting barbiturate; decreases cerebral metabolic rate and ICP; no analgesic properties

Muscle relaxants


  • IV/IO push: 0.1 mg/kg

  • 95% effective dose (ED95): 0.05 mg/kg

  • Onset: 3-5 minutes

  • Duration: 60-90 minutes

  • Side effects: Minimal cardiovascular effects

  • Notes: Nondepolarizing agent; degrades spontaneously, independent of organ elimination


  • IV/IO push: 0.6-1.2 mg/kg, 1.2 mg/kg dose used for RSI

  • ED95: 0.3 mg/kg

  • Onset: 60-90 seconds

  • Duration: 55-80 minutes

  • Side effects: Minimal cardiovascular effects

  • Notes: Nondepolarizing agent; rapid onset of action


  • IV/IO push: 1-1.5 mg/kg

  • ED95: 0.5 mg/kg

  • Onset: 45-60 seconds

  • Duration: 5-10 minutes

  • Side effects: Muscle fasciculations; may cause rhabdomyolysis; rise in intracranial, intraocular, intragastric pressure; life-threatening hyperkalemia

  • Notes: Depolarizing muscle relaxant; rapid onset, short duration of action; avoid in renal failure, burns, crush injuries after 48 hours, muscular dystrophy, other neuromuscular diseases, hyperkalemia, or family history of malignant hyperthermia; do not use to maintain paralysis


  • IV/IO push: 0.1 mg/kg

  • ED95: 0.05 mg/kg

  • Onset: 3-5 minutes

  • Duration: 50-80 minutes

  • Side effects: Minimal cardiovascular effects

  • Notes: Nondepolarizing agent; the higher the dose, the quicker the onset of action and the longer the duration



  • IV/IO push: 0.01-0.02 mg/kg; minimum dose 0.1 mg; maximum dose 0.5 mg

  • Onset: 1-2 minutes

  • Duration: 2-4 hours

  • Side effects: Paradoxical bradycardia can occur with doses < 0.1 mg, tachycardia, agitation

  • Notes: Antisialagogue; inhibits bradycardic response to hypoxia, laryngoscopy, and succinylcholine; may cause pupil dilation


  • IV/IO push: 0.005-0.01 mg/kg; maximum dose, 0.2 mgOnset: 1-2 minutes

  • Duration: 4-6 hours

  • Side effects: Tachycardia

  • Notes: Antisialagogue; inhibits bradycardic response to hypoxia, laryngoscopy, and succinylcholine


  • IV/IO push: 1.5 mg/kg

  • Onset: 1-2 minutes

  • Duration: 10-20 minutes

  • Side effects: Myocardial and CNS depression; seizures with high doses

  • Notes: May decrease ICP during RSI; may decrease pain on propofol injection

Fentanyl citrate

  • IV/IO push: 2-5 µg/kg

  • Onset: 1-3 minutes

  • Duration: 30-60 minutes

  • Side effects: Chest wall rigidity possible with high-dose rapid infusions

  • Notes: Minimum histamine release; may lower blood pressure (especially with higher doses or in conjunction with benzodiazepine)