Paediatric Rapid Sequence Intubation

Reviewed and revised 2 December 2014


  • 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


  • 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

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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