Lesson 6 of 16
In Progress

Rapid Sequence Intubation (RSI): Etomidate For RSI

Mechanism of action

Etomidate is GABA receptor agonist that blocks neuroexcitation and induces unconsciousness.

Etomidate is imidazole-derived which is sedative-hypnotic that is a commonly used induction agent for RSI.


  • The most common dose used is 0.3 mg/kg IV
    • An adjusted body weight is recommended in morbidly obese patients.


  • 15-45 seconds


  • 3-12 minutes

Adverse effects

  • Myoclonus can occur 25-63%
    • Can be mistaken for seizure activity
  • Pain on injection
    • Thought to be due to diluent propylene glycol
  • Adrenal Suppression
    • Inhibits corticoneogenesis and 11β-hydroxylation which may decrease cortisol and aldosterone levels, resulting in prolonged suppression.
  • Etomidate causes reduction in intraocular pressure (IOP).

Impact on Hemodynamics

Blood Pressure (BP) Heart Rate (HR) Cardiac Output (CO)Intracranial Pressure (ICP)
↔ No Impact ↔ No Impact ↔ No Impact ↓ Decrease
Etomidate Impact on Hemodynamics


  • Etomidate has no analgesic effects.
Gold standard induction agent for RSI

Literature Review

Author, year Design/ sample size Intervention & ComparisonOutcome
Lyons, 2015Cohort study/ n=261Etomidate+ Succinylcholine (Group 1)


Fentanyl+ ketamine+ rocuronium (Group 2)
Significantly better laryngeal views with fentanyl/ketamine/rocuronium group

100% first attempt intubation with fentanyl/ketamine/rocuronium group

↑ post-intubation MAP+ HR with etomidate + succinylcholine
Bruder, 2015Cochrane ReviewEtomidate
There was no difference in mortality, hospital LOS, duration of ventilation, and duration of vasopressors

Etomidate associated with ↑ ACTH and ↓ in cortisol level
Tekwani K, 2010RCT/ n=122Etomidate 0.3 mg/kg
Midazolam 0.1 mg/kg
No significant differences in median hospital LOS (9.5 vs 7.3 days), ICU LOS (4.2 vs 3.1 days), In-hospital mortality ( 26% vs 43%), or ventilator days
Jabre P,
RCT/ n=469Etomidate 0.3 mg/kg
Ketamine 2 mg/kg
No difference in intubating condition, SOFA score, 28-day mortality, Ventilator free days, vasopressor support, or GCS
ACHT= Adrenocorticotropic hormone; GCS= Glasgow Coma; HR= Heart Rate; MAP= Mean Arterial Pressure; RCT= Randomized Controlled Trial; Scale; SOFA= Sequential Organ Failure Assessment;