Rapid overview of rapid sequence intubation in children

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Rapid overview of rapid sequence intubation in children

Preparation: Utilize an active checklist to:

Begin preoxygenation as described below.

Identify conditions that will affect choice of medications (eg, increased intracranial pressure,
septic shock, bronchospasm, status epilepticus, or, if succinylcholine use is planned, absolute
contraindications for its use as listed below).

Identify conditions that will predict difficult intubation or bag-mask ventilation (eg, small chin,
inability to fully open the mouth, upper airway trauma, or infection).

Assemble equipment and check for function.

Develop contingency plan for failed intubation (refer to UpToDate topics on devices for difficult
endotracheal intubation).

Preoxygenation
Begin preoxygenation as soon as rapid sequence intubation is potentially needed:
Spontaneously breathing: 100% FiO 2 (7 L/min oxygen flow) by nonrebreather mask for 3
minutes
Apneic or inadequate breathing: Bag-mask ventilation with small tidal breaths using 100%
FiO 2
During induction and paralysis, apneic oxygenation via nasal cannula at flow rate of 1
L/kg/min (maximum flow 15 L/min) may be provided

Administer oxygen at the highest concentration available.

Pretreatment (optional)
Atropine: Although not routinely recommended, many experts suggest atropine as pretreatment
for:
Children ≤1 year
Children in shock
Children <5 years receiving succinylcholine
Older children receiving a second dose of succinylcholine
Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 0.5 mg; if no IV access,
can be given IM).

Fentanyl: Optional for increased intracranial pressure in patients with normal or elevated blood
pressure. Dose: 1 to 3 mcg/kg given over 30 to 60 seconds to avoid respiratory depression and
chest wall rigidity. Give 3 minutes before induction agent is administered.

Lidocaine: Optional for increased intracranial pressure (not recommended for pretreatment in
children by some airway experts). Dose: 1 to 2 mg/kg IV (maximum dose 200 mg). Give 2 to 3
minutes before intubation.

Sedation

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Rapid overview of rapid sequence intubation in children
Etomidate:

Safe with hemodynamic instability, neuroprotective, transient adrenal cortico-suppression. Do

not use routinely in patients with septic shock.
Dose: 0.3 mg/kg IV.

Ketamine:

Safe with hemodynamic instability if patient is not catecholamine depleted. Use in patients
with bronchospasm and septic shock. Use with caution in hypertensive patients with
increased intracranial pressure.
Dose: 1 to 2 mg/kg IV (if no IV access, can be given IM dose: 3 to 7 mg/kg).

Propofol:

Causes hypotension. May use in hemodynamically stable patients with status epilepticus.
Dose 1 to 1.5 mg/kg IV.

Midazolam:

May use in hemodynamically stable patients with status epilepticus. Time to clinical effect is
longer, inconsistently induces unconsciousness. May cause hemodynamic instability at doses
required for sedation.
Dose: 0.2 to 0.3 mg/kg IV (maximum dose 10 mg, onset of effect requires 2 to 3 minutes).

Fentanyl:

Optional for cardiogenic shock or catecholamine-depleted shock (eg, persistent hypotension

despite vasopressor therapy). Limited evidence in children.
Dose 1 to 5 mcg/kg titrated to effect. Start at lower end of range in hypotensive patients. Give
over 30 to 60 seconds to avoid respiratory depression or chest wall rigidity.

Thiopental:

Neuroprotective. Do not use with hemodynamic instability.

Dose: 3 to 5 mg/kg IV.*

Paralytic
Rocuronium:

Use for children with contraindication for succinylcholine or as primary paralytic if

sugammadex is immediately available.
Dose: 1 mg/kg IV. ¶

Succinycholine:

Do not use with extensive crush injury with rhabdomyolysis, chronic skeletal muscle disease
(eg, Becker muscular dystrophy) or denervating neuromuscular disease (eg, cerebral palsy
with paralysis); 48 to 72 hours after burn, multiple trauma, or denervating injury; patients
with history or malignant hyperthermia; or pre-existing hyperkalemia.
Dose: Infants and children ≤2 years: 2 mg/kg IV, older children and adolescents: 1 to 1.5

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Rapid overviewDose:
of rapidInfants
sequence intubation
and childrenin children
≤2 years: 2 mg/kg IV, older children and adolescents: 1 to 1.5
mg/kg IV (if IV access unobtainable, can be given IM, dose: 4 mg/kg). Δ

Protection and positioning

Maintain manual cervical spine immobilization during intubation in the trauma patient.

If cervical spine injury is not potentially present, put the patient in the "sniffing position" (ie,
head forward so that the external auditory canal is anterior to the shoulder and the nose and
mouth point to the ceiling).

Utilize external laryngeal manipulation or, in infants, gentle cricoid pressure to optimize the view
of the glottis during direct laryngoscopy if the initial view is suboptimal or inadequate despite
correct laryngoscope blade positioning. ◊

Positioning, with placement

Confirm tracheal tube placement with end-tidal CO 2 detection and auscultation.

Postintubation management

Obtain a chest radiograph to confirm the depth of tracheal tube insertion.

Provide ongoing sedation (eg, midazolam), analgesia (eg, fentanyl 1 mcg/kg), and, if indicated,
paralysis. §

If IV access is not rapidly obtained, intraosseous administration of drugs is an acceptable

alternative.

IM: intramuscularly; IV: intravenously.

* Not available in many countries, including the United States and Canada.
¶ Sugammadex in a dose of 16 mg/kg can provide immediate reversal of paralysis when given
approximately 3 minutes after a single dose of rocuronium or vecuronium. Vecuronium may be used in
children with contraindications to succinylcholine and when rocuronium is not available. Suggested dose
for rapid sequence intubation: vecuronium 0.15 to 0.2 mg/kg. Patients may experience prolonged and
unpredictable duration of paralysis at this dose.
Δ Defasciculating agents (eg, rocuronium or vecuronium at one-tenth of the paralyzing dose) are not
routinely recommended for children receiving succinylcholine. Onset of paralysis is slower by the
intramuscular route; the clinician must ensure full pre-oxygenation prior to administration, whenever
possible, and be prepared to perform bag-mask ventilation if desaturation occurs before the patient is
fully paralyzed for endotracheal intubation.
◊ Bimanual laryngoscopy, also called external laryngeal manipulation (ELM), entails manipulating the
thyroid cartilage or hyoid bone with the right hand during laryngoscopy in order to improve the view of
the glottis. For a description of how to perform ELM, refer to topics on emergency endotracheal intubation
in children and rapid sequence intubation in children.
§ If decompensation occurs after successful intubation, use the DOPE mnemonic to find the cause: ​
D: Dislodgement of the tube (right mainstem or esophageal)
O: Obstruction of tube
P: Pneumothorax
E: Equipment failure (ventilator malfunction, oxygen disconnected or not on)

Graphic 51456 Version 36.0

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Rapid overview of rapid sequence intubation in children
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