Clinical Guideline Updates for RSI and the Agitated Patient

Severe agitation in the emergency department is best managed with targeted chemical sedation, and rapid sequence intubation outcomes depend as much on preparation as on the induction drug. Current ACEP and SCCM guidance sharpens first-line drug choices for agitation, paralytics, induction agents, and preoxygenation in critically ill adults.

Agitated Patient Sedation Updates

• Preferred single-agent sedation: Droperidol is the guideline-preferred single agent for ED agitation, with haloperidol as the practical fallback when droperidol is unavailable or unfamiliar.
• Most effective combination therapy: For severe agitation, an antipsychotic plus a benzodiazepine is the most effective medication strategy, and midazolam is favored over lorazepam for faster, more predictable onset.
• Benzodiazepine monotherapy downside: Benzodiazepines alone are no longer the favored approach for routine ED agitation because they underperform compared with droperidol-based strategies and bring more adverse-effect baggage.
• Ketamine for immediate control: Ketamine is the rapid option when agitation creates an immediate safety threat to the patient, staff, or bystanders, especially at the extreme end of agitation scales. We get into where that threshold really sits in the episode.
• Older and prehospital gaps: The guideline does not make firm agent recommendations for prehospital agitation or for adults over 65, where cause of agitation and psychiatric history start to matter more than blanket rules.

RSI Guideline Updates

• Routine paralytic recommendation: A neuromuscular blocking agent is recommended for rapid sequence intubation, and either rocuronium or succinylcholine is acceptable when succinylcholine has no contraindication.
• Etomidate versus ketamine: Etomidate is not inferior to other induction agents such as ketamine for peri-intubation hypotension, vasopressor use, or mortality, which supports keeping it in regular RSI practice.
• High-flow oxygen strategy: High-flow nasal oxygen is recommended when laryngoscopy is expected to be difficult, giving you more oxygen reserve during an airway that may not be straightforward. We walk through the practical setup in the chapter.
• NIPPV for severe hypoxemia: Noninvasive positive pressure ventilation is recommended for severe hypoxemia before RSI and can occasionally avert intubation while freeing hands during a complex resuscitation.
• Preparation over dogma: The guideline shifts RSI decision-making away from induction-drug dogma and toward structured preparation, especially preoxygenation choices matched to the physiology in front of you.

References:

1. ACEP Clinical Policy Update: Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation. https://www.acep.org/siteassets/new-pdfs/clinical-policies/severe-agitation-cp.pdf
2. Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient: Executive Summary. Crit Care Med. 2023;51(10):1407-1410.   PMID: 37707378