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
- 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
- Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: a review. Pediatr Emerg Care. 2004 May;20(5):339-44. Review. PubMed PMID: 15123910.
- Engelhardt T. Rapid sequence induction has no use in pediatric anesthesia. Paediatr Anaesth. 2014 Sep 30. doi: 10.1111/pan.12544. [Epub ahead of print] PubMed 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. PubMed 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. doi: 10.1016/j.annemergmed.2012.02.013. Epub 2012 Mar 15. PubMed PMID: 22424653; PubMed Central PMCID: 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. Review. PubMed PMID: 15891426.