Paediatric Rapid Sequence Intubation

Reviewed and revised 2 December 2014

OVERVIEW

• RSI is used to secure the airway quickly with an endotracheal tube and to prevent chance of regurgitation and aspiration
• the basic approach is similar to that in adults
• Note that pretreatment with atropine, while traditionally given prior to intubation in children, is generally not necessary
• follow this link for differences in the paediatric airway

PROCEDURE

• Preoxygenation
  • 4 vital capacity breaths or until ETO2 is concentration >90%
  • this may be difficult with an uncooperative child, a cautious dose of fentanyl 0.25mcg/kg IV provides a slightly sedated more compliant child, however caution needs to be taken as airway protection must be maintained, not normally a problem for small children, but older ones may kick up a fuss
• Suction prepared and under pillow
• Apneic oxygenation via nasal prongs
• Induction with thiopentone 3-6mg/kg IV as long as patients haemodynamics will tolerate this dose
  • choice of induction age and dose may be modified according to clinical context (e.g. propofol, etomidate)
• Cricoid pressure applied by skilled assistance (optional)
• Suxamethonium 1-2mg/kg IV (2mg/kg for neonates, and 1mg/kg children) OR rocuronium 1.2mg/kg IV
• Once patient fasciculated/ paralysed perform rapid laryngoscopy with placement of a endotracheal tube
  • ETT size = age/4 + 4
  • traditionally uncuffed until age 8, then cuffed (a ‘one-size smaller’ cuffed tube can be used in children <8 years)
  • leak should occur at 20cmH2O if uncuffed
• check endotracheal tube placement by:
  • observing tube fogging, chest rising and falling, auscultation of in both axillae and observing end tidal CO2
  • if child is >2 years old then endotracheal tube should be at lips by formula age/2 + 12cm
• once endotracheal tube is satisfactory position cricoid pressure can be released
• if a nasogastric tube is in situ leave in place during the procedure as will help decompress stomach if bag-mask ventilation required, remove post procedure if indicated

References and links

Journal articles

• Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: a review. Pediatr Emerg Care. 2004 May;20(5):339-44. PMID: 15123910.
• Engelhardt T. Rapid sequence induction has no use in pediatric anesthesia. Paediatr Anaesth. 2014 Sep 30. PMID: 25265988.
• Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004 Oct;20(10):651-5. PMID: 15454737.
• Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012 Sep;60(3):251-9. PMC3400706.
• Zelicof-Paul A, Smith-Lockridge A, Schnadower D, Tyler S, Levin S, Roskind C, Dayan P. Controversies in rapid sequence intubation in children. Curr Opin Pediatr. 2005 Jun;17(3):355-62 PMID: 15891426.

FOAM and web resources

• RCH Melbourne CPG — emergency airway management
• RCH Melbourne Trauma — airway procedures
• RCH Melbourne TRauma — airway management