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Drug Order in Rapid Sequence Intubation

Driver BE et al. Drug Order in Rapid Sequence Intubation.

Acad Emerg Med September 2019 Vol 26 No 9: 1014-1021

Question they asked
Does drug order administration affect the time to successful first intubation attempt?

Study Design
A secondary analysis of a previously published randomised trial(1), that compared bougie and stylet for intubation.

The primary outcome was intubation time. ie., the time from administration of first RSI drug, to removal of laryngoscope blade(end of attempt).

n = 562
153 patients had induction agent given first and 409 had neuromuscular blocker given first.


  • 99% of the patients received Etomidate as the sedating age. Not everyone has etosidate.
  • There was a large proportion receiving paralytic first. There was an obvious sample size difference.
  • Apnoea time measured was not true time, but a surrogate marker.

The study concludes that there is a small decrease in total intubation time, however not statistically significant.

We certainly need more work on this. It sensibly appears that if the paralytic agent is given first followed by the sedating agent, it may decrease time to intubation, as compared with giving sedation and waiting and then giving paralytic.


  1. Driver BE et al. Effect of use of a bougie vs endotracheal tube and stylet on first attempt intubation success among patients with difficult airways undergoing emergency intubation:a randomised clinical trial. JAMA 2018;319:2179-2189