Pretreatment drugs for RSI


Traditionally there are four options for pretreatment for Rapid Sequence Intubation (RSI):

  • atropine 20 mcg/kg IV — prevent bradycardia in children
  • lignocaine 1.5mg/kg IV — sympatholytic, neuroprotection in head injury; decrease airway reactivity in asthma
  • fentanyl 2-3 mcg/kg IV — sympatholytic, neuroprotection in head injury and vascular emergencies (e.g. myocardial ischaemmia, aortic dissection, subarachnoid haemorrhage)
  • defasciculating dose of a non-depolarising neuromuscular blocker (e.g. rocuronium 0.1 mg/kg IV or vecuronium 0.01 mg/kg IV) — prevents fasciculations from suxamethonium (e.g. TBI)

Other agents suggested as pretreatment for rapid sequence induction:

  • remifentanil
  • gabapentin


  • There is little evidence that any of these are beneficial clinically
  • They should not be a routine part of clinical practice but may be considered in selected patients by skilled practitioners

References and Links

Journal articles

  • Kovacs G, Macquarrie K, Campbell S. Pretreatment in rapid sequence intubation: Indicated or contraindicated? CJEM. 2006 Jul;8(4):243; author reply 243-4. PMID: 17324300.
  • Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001 Sep;18(5):373-5. PMC1725690.
  • Butler J, Jackson R. Best evidence topic report. Lignocaine as a pretreatment to rapid sequence intubation in patients with status asthmaticus. Emerg Med J. 2005 Oct;22(10):732. PMC1726553.

FOAM and web resources

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.