Drug-assisted and Rapid Sequence Intubation Practice Questions

30 multiple-choice questions on Drug-assisted and rapid sequence intubation for paramedic and EMT students, from Chapter 16 (Airway Management). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. What is the main goal of rapid sequence intubation?

   1. A. Keep the patient breathing on his own
   2. B. Prevent post-intubation hypotension
   3. C. Avoid the need for preoxygenation
   4. D. Rapid control with less aspiration
   Show answer

   Answer: D. Rapid control with less aspiration

   RSI gives an induction agent and paralytic in rapid succession to produce optimal intubating conditions quickly while minimizing the time the airway is unprotected. RSI drugs and positive pressure often lower BP rather than prevent hypotension, preoxygenation remains essential because the patient will be apneic, and paralysis removes the patient's own breathing rather than keeping it.

2. In the classic "7 Ps" of RSI, which step comes first?

   1. A. Preoxygenation
   2. B. Paralysis
   3. C. Preparation
   4. D. Positioning
   Show answer

   Answer: C. Preparation

   The 7 Ps are Preparation, Preoxygenation, Pretreatment/optimization, Paralysis with induction, Positioning/protection, Placement with proof, and Postintubation management.

3. How long should a patient generally be preoxygenated before RSI when time allows?

   1. A. About 30 seconds
   2. B. At least 3 minutes
   3. C. At least 20 minutes
   4. D. About 15 seconds
   Show answer

   Answer: B. At least 3 minutes

   Three minutes of high-concentration oxygen (or 8 vital capacity breaths in a cooperative patient) replaces nitrogen in the lungs and extends safe apnea time.

4. What is apneic oxygenation?

   1. A. BVM breaths during apnea
   2. B. Jet ventilation via the neck
   3. C. CPAP given after intubation
   4. D. Nasal O2 during apnea
   Show answer

   Answer: D. Nasal O2 during apnea

   A nasal cannula at high flow (often 15 L/min) left on during laryngoscopy lets oxygen continue to diffuse into the alveoli, delaying desaturation.

5. A 150-kg man needs RSI with succinylcholine. Which weight should the dose be based on?

   1. A. Ideal body weight
   2. B. Half of total weight
   3. C. Total body weight
   4. D. A fixed 100-mg dose
   Show answer

   Answer: C. Total body weight

   Succinylcholine is dosed on total body weight (1.5 mg/kg) because obese patients have more pseudocholinesterase and extracellular fluid; ideal-weight dosing gives incomplete paralysis. Ideal body weight is used for rocuronium by many guides, not succinylcholine. Halving the dose or using a fixed 100 mg underdoses him.

6. To get the best preoxygenation in a breathing patient before RSI, which setup is most effective?

   1. A. Nonrebreather at flush rate plus a nasal cannula
   2. B. A nonrebreather at 10 L/min with no nasal cannula
   3. C. Nasal cannula at 6 L/min by itself
   4. D. Simple face mask at 8 L/min
   Show answer

   Answer: A. Nonrebreather at flush rate plus a nasal cannula

   Running the nonrebreather at flush rate (oxygen regulators often allow 40 L/min or more) keeps the reservoir full and limits room-air entrainment, and a nasal cannula at 15 L/min adds oxygen during preoxygenation and apneic oxygenation. A nonrebreather at 10 L/min lets the bag collapse. A 6-L/min cannula gives about 44% oxygen. A simple face mask cannot reach high FiO2.

7. After 3 minutes on a nonrebreather, a pneumonia patient's SpO2 is still 88% before planned RSI. What is the best next step?

   1. A. Proceed; 88% is enough to start
   2. B. Add PEEP with a BVM or start CPAP
   3. C. Give the paralytic now to save time
   4. D. Switch to a nasal cannula at 6 L/min
   Show answer

   Answer: B. Add PEEP with a BVM or start CPAP

   Hypoxemia that persists on high-flow oxygen means shunt from collapsed alveoli. PEEP (BVM with a PEEP valve or CPAP) recruits them and raises the oxygen reserve before apnea. Starting at 88% leaves almost no safe apnea time. Paralyzing early removes the patient's own breathing. A nasal cannula delivers less oxygen.

8. Your patient weighs 80 kg. How much succinylcholine is needed at 1.5 mg/kg?

   1. A. 120 mg
   2. B. 160 mg
   3. C. 100 mg
   4. D. 80 mg
   Show answer

   Answer: A. 120 mg

   1.5 mg/kg x 80 kg = 120 mg.

9. Why is rocuronium dosed at 1 to 1.2 mg/kg for RSI rather than the 0.6 mg/kg used in the operating room?

   1. A. The larger dose shortens the duration
   2. B. The smaller dose causes fasciculations
   3. C. The smaller dose raises potassium
   4. D. The larger dose speeds the onset
   Show answer

   Answer: D. The larger dose speeds the onset

   Higher doses of rocuronium bring intubating conditions in about 45 to 60 seconds, close to succinylcholine; 0.6 mg/kg takes longer. The larger dose lengthens, not shortens, the duration. Rocuronium is nondepolarizing and does not cause fasciculations or raise potassium at any dose.

10. A 20-kg child needs rocuronium 1 mg/kg for RSI. The vial contains 10 mg/mL. What volume should you draw up?

    1. A. 0.2 mL
    2. B. 2 mL
    3. C. 20 mL
    4. D. 1 mL
    Show answer

    Answer: B. 2 mL

    1 mg/kg x 20 kg = 20 mg. At 10 mg/mL, 20 mg is 2 mL. 0.2 mL (2 mg) and 1 mL (10 mg) underdose the child, and 20 mL (200 mg) is a tenfold overdose from confusing milligrams with milliliters.

11. A head-injured trauma patient with a BP of 86/54 needs RSI. A colleague worries that ketamine will raise intracranial pressure. What does current evidence show?

    1. A. Ketamine is contraindicated after head injury
    2. B. Propofol is preferred to protect the brain
    3. C. Induction drugs should be skipped here
    4. D. Ketamine is acceptable and helps keep up BP
    Show answer

    Answer: D. Ketamine is acceptable and helps keep up BP

    Studies do not show that ketamine harmfully raises ICP in ventilated patients, and it supports blood pressure, which protects cerebral perfusion; hypotension is far more harmful to the injured brain. The old contraindication is no longer supported. Propofol drops BP, which is dangerous here. Skipping induction leaves the patient aware and raises ICP from laryngoscopy.

12. Shortly after succinylcholine is given, you notice brief muscle twitching across the trunk and limbs. What are these?

    1. A. Seizures
    2. B. Fasciculations
    3. C. Myoclonus from etomidate
    4. D. Shivering
    Show answer

    Answer: B. Fasciculations

    Fasciculations reflect the initial depolarization caused by succinylcholine and are followed by paralysis.

13. A colleague wants to give IV lidocaine before RSI in a head-injured patient to protect the brain. What is the best response?

    1. A. It is a required step in head-injury RSI
    2. B. It replaces the need for a separate induction agent
    3. C. It is not supported by good outcome evidence
    4. D. It reverses the effect of succinylcholine
    Show answer

    Answer: C. It is not supported by good outcome evidence

    Lidocaine pretreatment was once used to blunt ICP rises during laryngoscopy, but studies have not shown better outcomes, and current emergency airway practice does not use it routinely. It is not a required step. It does not replace a separate induction agent. It does not reverse succinylcholine.

14. After succinylcholine, you cannot intubate and cannot ventilate. Why should you not simply wait for the drug to wear off?

    1. A. Succinylcholine paralysis lasts for several hours
    2. B. Waiting raises potassium to fatal levels
    3. C. The patient will wake up still paralyzed
    4. D. Severe desaturation comes before it wears off
    Show answer

    Answer: D. Severe desaturation comes before it wears off

    Even though succinylcholine lasts only about 5 to 10 minutes, a patient with no ventilation reaches critical desaturation before breathing returns, so a failed airway needs a rescue device or surgical airway, not waiting. It does not last hours. Waiting does not cause a dangerous potassium rise. Consciousness may return during paralysis, but that is not the reason waiting fails.

15. Which patient is at increased risk of dangerous hyperkalemia from succinylcholine?

    1. A. Major burns 5 days ago
    2. B. Burns from 30 minutes ago
    3. C. Acute asthma exacerbation
    4. D. A healthy 25-year-old
    Show answer

    Answer: A. Major burns 5 days ago

    Receptor upregulation after burns, crush injuries, and denervation begins after roughly 24 to 72 hours, so succinylcholine is safe acutely but dangerous days later.

16. Before giving a paralytic to a patient with a head injury, what should you document?

    1. A. The time of the patient's last meal
    2. B. His GCS, pupils, and limb movement
    3. C. A full set of orthostatic vital signs
    4. D. The patient's blood type and allergies
    Show answer

    Answer: B. His GCS, pupils, and limb movement

    Paralysis removes the neurologic exam for 30 minutes or more, so record the GCS, pupils, and limb movement first; receiving teams use this baseline. Last oral intake is useful but not the priority here. Orthostatic vitals are not done in a patient needing RSI. Blood type is not known in the field, and allergies are part of the history but not the exam that paralysis erases.

17. Which drug can rapidly reverse rocuronium-induced paralysis?

    1. A. Atropine
    2. B. Flumazenil
    3. C. Sugammadex
    4. D. Naloxone
    Show answer

    Answer: C. Sugammadex

    Sugammadex encapsulates rocuronium and reverses its effect. It is not routinely carried by most EMS services.

18. During RSI, how should the induction agent be given?

    1. A. Titrated slowly until eyes close
    2. B. As a full dose by rapid IV push
    3. C. Spread out over about 5 minutes
    4. D. After the paralytic takes effect
    Show answer

    Answer: B. As a full dose by rapid IV push

    In RSI the induction agent is pushed rapidly as a full dose and followed at once by the paralytic, so the patient goes from awake to intubating conditions quickly with little time unprotected. Titrating slowly until the eyes close is for procedural sedation. A 5-minute push prolongs the vulnerable period. Giving it after the paralytic risks awareness under paralysis.

19. After induction and paralysis, a patient's SpO2 falls to 91% while you wait for the paralytic to take effect. What is reasonable?

    1. A. Leave him apneic until the tube is placed
    2. B. Forceful breaths at a fast rate
    3. C. Intubate at once before full onset
    4. D. Gentle bag-mask breaths at low pressure
    Show answer

    Answer: D. Gentle bag-mask breaths at low pressure

    Gentle BVM ventilation between induction and laryngoscopy reduced severe hypoxemia without raising aspiration in the PreVent trial. Leaving a desaturating patient apneic risks dangerous hypoxemia. Forceful, fast breaths inflate the stomach. Attempting laryngoscopy before full paralysis worsens the view and can cause vomiting or laryngospasm.

20. Why is etomidate a common choice for induction in many patients?

    1. A. It lasts several hours
    2. B. Little effect on BP
    3. C. It provides analgesia
    4. D. It reverses easily
    Show answer

    Answer: B. Little effect on BP

    Etomidate is relatively hemodynamically neutral. It provides no analgesia and can cause myoclonus and transient adrenal suppression.

21. A patient with severe angioedema is still breathing on his own but has very difficult predicted anatomy. Why is standard RSI risky?

    1. A. Paralytics worsen the airway swelling itself
    2. B. Paralysis takes away his own breathing
    3. C. RSI drugs need a longer onset here
    4. D. Induction drugs reverse epinephrine
    Show answer

    Answer: B. Paralysis takes away his own breathing

    If intubation and mask ventilation both fail after paralysis, the patient has no breathing of his own and becomes a cannot-intubate, cannot-oxygenate emergency. Keeping spontaneous breathing (an awake approach) with a surgical airway ready is safer when anatomy is very difficult. Paralytics do not worsen angioedema. Onset times are unchanged. Induction agents do not reverse epinephrine.

22. A 40-year-old trauma patient needs RSI. His BP is 78/50 and HR 130. What is the most important step before induction?

    1. A. Hyperventilate after the tube
    2. B. Resuscitate before intubation
    3. C. Give a full propofol dose
    4. D. Delay fluids until after the tube
    Show answer

    Answer: B. Resuscitate before intubation

    Induction agents and positive-pressure ventilation can precipitate arrest in shocked patients. Restore perfusion and consider reduced induction doses. Fluids or blood should be given before induction, not delayed until after the tube; hyperventilation after intubation further lowers venous return, and a full propofol dose can cause profound hypotension.

23. An agitated, hypoxic patient keeps pulling off his nonrebreather and cannot be preoxygenated. Some protocols use ketamine to permit preoxygenation before paralysis. This is called:

    1. A. Rapid sequence induction
    2. B. Awake fiberoptic intubation
    3. C. Delayed sequence intubation
    4. D. Crash airway intubation
    Show answer

    Answer: C. Delayed sequence intubation

    In delayed sequence intubation, a dissociative dose of ketamine calms the patient while preserving breathing so preoxygenation can be completed before paralysis.

24. After intubation with rocuronium, the patient becomes tachycardic and hypertensive and tears run from his eyes. What is the most likely cause?

    1. A. Return of paralysis
    2. B. Inadequate sedation
    3. C. Hypoglycemia
    4. D. Tube in the bronchus
    Show answer

    Answer: B. Inadequate sedation

    Paralytics provide no sedation or analgesia. Signs of sympathetic stimulation suggest the patient is aware and needs sedation and analgesia.

25. An adult in cardiac arrest is apneic, pulseless, and flaccid, and needs intubation. Which RSI drugs are needed?

    1. A. Etomidate and rocuronium
    2. B. None; intubate without them
    3. C. Ketamine and succinylcholine
    4. D. Midazolam followed by fentanyl
    Show answer

    Answer: B. None; intubate without them

    A 'crash airway' patient is unresponsive with no tone, so induction agents and paralytics add nothing and only delay the airway; intubate (or place an SGA) with minimal interruption of compressions. Giving etomidate, ketamine, paralytics, midazolam, or fentanyl in arrest is not indicated for intubation.

26. What is the current recommendation regarding routine cricoid pressure during RSI and cardiac arrest?

    1. A. It is advised during bag-mask CPR
    2. B. It is not routinely recommended
    3. C. It is advised for RSI, not for CPR
    4. D. It is required for every case
    Show answer

    Answer: B. It is not routinely recommended

    Cricoid pressure can worsen the laryngoscopic view and impede ventilation, and evidence of benefit is weak. It is not recommended routinely during cardiac arrest, including bag-mask ventilation, and it is not routinely recommended for RSI either; it may be used selectively but is not mandatory.

27. After 1 minute of laryngoscopy without success, the patient's SpO2 has fallen to 86%. What should you do?

    1. A. Push on for 30 seconds
    2. B. Begin a cricothyrotomy
    3. C. Give another paralytic
    4. D. Stop and reoxygenate
    Show answer

    Answer: D. Stop and reoxygenate

    Abort the attempt and reoxygenate with a BVM or SGA. A surgical airway is indicated only if oxygenation cannot be maintained by other means.

28. After intubation, a patient's BP is 88/56 and he needs ongoing sedation. Which option is the better choice?

    1. A. Small doses of ketamine
    2. B. A propofol infusion
    3. C. A 5-mg midazolam bolus
    4. D. Rocuronium without sedation
    Show answer

    Answer: A. Small doses of ketamine

    Ketamine keeps up sympathetic tone and is the usual choice for sedating a hypotensive patient. Propofol and a large midazolam bolus both lower blood pressure further. A paralytic alone gives no sedation or analgesia and leaves the patient aware.

29. Which agent is commonly used to blunt the sympathetic response to laryngoscopy?

    1. A. Fentanyl
    2. B. Rocuronium
    3. C. Succinylcholine
    4. D. Atropine
    Show answer

    Answer: A. Fentanyl

    Fentanyl blunts the rise in heart rate and blood pressure from laryngoscopy, which may help in patients with head injury or aortic emergencies.

30. Why is midazolam a poor choice as the only induction agent for RSI in a hypotensive patient?

    1. A. It causes muscle rigidity and fever
    2. B. It lowers BP and acts slowly at full doses
    3. C. It raises potassium in muscle cells
    4. D. It strongly constricts the bronchial muscle
    Show answer

    Answer: B. It lowers BP and acts slowly at full doses

    Midazolam has a slower onset than etomidate or ketamine at induction doses and causes dose-related hypotension, both poor traits in RSI for a hypotensive patient. Rigidity and fever describe malignant hyperthermia triggers, not midazolam. It does not raise potassium. It does not constrict the bronchi or their muscle.