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There has been some interesting debate in the past couple weeks in the #FOAMed community about the proper sequence to deliver RSI medications. Specifically, the debate centers around whether to administer Ketamine or Rocuronium first when performing RSI. Rocuronium is a non-depopmarizing paralytic that has an onset time of approximately 60-90 seconds. Ketamine, meanwhile is a wonderful sedative that has an onset time of approximately 30 seconds. The method of introducing rocuronium first has been called Rocketamine, which to be honest is an awesome name for a medical intervention. Giving ketamine first has been called Ketaronium, which has a less awesome name, but might be a better sequence for EMS.

When working in the pre-hospital environment, we do not always have the luxury of working in a controlled environment. While the literature surrounding these different means of induction support administering rocuronium first, there does not seem to be compelling data to suggest that it would be a more effective intervention when working in EMS. The additional variables to this are other drugs in our RSI arsenal such as etomidate, or perhaps propofol. Beyond that, it can be problematic giving these drugs in the field when a patient has a difficult airway that we cannot predict. The in-hospital setting makes it profoundly easier to make these calls, and the issues of unpredictability in the EMS environment are often overlooked.

You can find the articles that are cited here and here.