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Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults outside the operating room

David Caro, MD
Section Editor
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The first task of any clinician managing an acutely unstable patient is to secure the airway. In most circumstances, emergency clinicians use rapid sequence intubation (RSI) when active airway management is required. RSI incorporates neuromuscular blocking agents (NMBA) and rapidly acting sedative (ie, induction) medications to create optimal intubating conditions.

This topic review will discuss the basic clinical pharmacology and selection of NMBAs for use in RSI outside the operating room. The practice of RSI and other medications used as part of RSI are discussed elsewhere, as are other aspects of airway management both inside and outside the operating room. (See "Rapid sequence intubation for adults outside the operating room" and "Induction agents for rapid sequence intubation in adults" and "Pretreatment agents for rapid sequence intubation in adults" and "Basic airway management in adults" and "Rapid sequence induction and intubation (RSII) for anesthesia".)


RSI is the standard of care in emergency airway management for intubations not anticipated to be difficult [1-4]. RSI involves the use of a sedative and a neuromuscular blocking agent (NMBA) to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation, mitigate unwanted physiologic responses to laryngoscopy and intubation, and minimize the risk of aspiration. Multiple prospective observational studies confirm the excellent success rate of RSI using the combination of a sedative and a NMBA in the emergency department (ED) [2-4]. (See "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) in children".)

NMBAs are integral to the performance of RSI. Multiple observational studies demonstrate that the use of NMBAs improves success rates for emergency endotracheal intubation and reduces the risk of complications [1,5-9]. One prospective trial performed in a prehospital air medical setting and using a crossover design found the use of NMBAs improved the view of the larynx by a full grade in most patients when performing direct laryngoscopy [6].

In RSI, a NMBA is given in conjunction with a sedative agent. Patients undergoing RSI may be fully aware of their environment and painful stimuli, but unable to respond [10,11]. If such patients are not adequately sedated, potentially adverse physiologic responses to airway manipulation can occur, including tachycardia, hypertension, and elevated intracranial pressure (ICP) [12]. Sedative use prevents or minimizes these effects, and may also improve the laryngoscopic view obtained after neuromuscular paralysis [13,14]. (See "Induction agents for rapid sequence intubation in adults".)


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Literature review current through: Sep 2016. | This topic last updated: Oct 17, 2016.
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