Overview
Definition:
Rapid sequence intubation (RSI) is a procedure for securing the airway in critically ill or injured patients by administering a sedative and a paralytic agent concurrently, followed immediately by endotracheal intubation
In pediatric patients, RSI is crucial but requires careful consideration of weight-based dosing for all medications to ensure safety and efficacy.
Clinical Significance:
Effective airway management is paramount in pediatric emergencies
RSI minimizes the time from induction to intubation, thereby reducing the risk of aspiration, hypoxemia, and barotrauma associated with bag-mask ventilation
Accurate weight-based dosing is critical to avoid over-sedation or under-paralysis, which can lead to failed intubation attempts or adverse events.
Indications:
Indications for RSI in children are similar to adults and include inability to maintain oxygenation or ventilation, impending airway compromise (e.g., facial trauma, foreign body aspiration, severe anaphylaxis), severe head injury with altered mental status, and impending cardiac arrest.
Pharmacology And Dosing
Sedative Selection And Dosing:
Commonly used sedatives include etomidate (0.3 mg/kg IV), ketamine (1-2 mg/kg IV/IO), and midazolam (0.1-0.3 mg/kg IV)
Etomidate is often preferred for its hemodynamic stability
Ketamine provides bronchodilation and analgesia but can increase secretions and heart rate
Midazolam is a benzodiazepine with amnesic and anxiolytic properties.
Paralytic Selection And Dosing:
Succinylcholine (1-2 mg/kg IV/IO) is the most common paralytic agent for RSI in children due to its rapid onset and short duration
Rocuronium (0.6-1.2 mg/kg IV/IO) is an alternative, especially in patients with contraindications to succinylcholine or prolonged paralysis needs, though it has a slower onset and longer duration
Neuromuscular monitoring is recommended.
Induction Agents:
Ketamine: 1-2 mg/kg IV/IO
Etomidate: 0.3 mg/kg IV/IO
Midazolam: 0.1-0.3 mg/kg IV/IO
Propofol: 1-3 mg/kg IV/IO (use with caution in young children due to potential for propofol infusion syndrome and hypotension).
Paralytic Agents:
Succinylcholine: 1-2 mg/kg IV/IO
Rocuronium: 0.6-1.2 mg/kg IV/IO.
Pre Intubation Management
Assessment And Preparation:
Thorough assessment of the airway, including identification of potential difficult airway predictors (e.g., macroglossia, micrognathia, neck masses, previous airway surgery)
Ensure all equipment is readily available: laryngoscope with appropriate blade size, endotracheal tubes of various sizes, suction, ambu bag, oxygen source, and all necessary medications and IV access.
Oxygenation And Preoxygenation:
Administer high-flow oxygen via non-rebreather mask for 3-5 minutes to maximize oxygen reserves
For infants and spontaneously breathing children, apneic oxygenation can be achieved by continuing oxygen delivery via nasal cannula or by passing oxygen over the face during laryngoscopy.
Medication Preparation:
Calculate all drug doses based on the child's actual weight
Prepare medications in clearly labeled syringes
Double-check all calculations and dosages with a colleague
Have backup medications readily available.
Intubation Procedure And Post Intubation Care
Laryngoscopy And Intubation:
After administration of sedative and paralytic, perform laryngoscopy to visualize the vocal cords
Insert the appropriately sized endotracheal tube
Confirm correct placement by observing chest rise, bilateral breath sounds, absence of epigastric sounds, and capnography (gold standard).
Securing The Tube:
Secure the endotracheal tube firmly with tape or a commercial tube holder to prevent dislodgement
Consider a correctly sized oral airway if needed for jaw support or to prevent biting the tube.
Post Intubation Management:
Initiate mechanical ventilation with appropriate tidal volume and respiratory rate
Obtain a post-intubation chest X-ray to confirm tube position
Administer further sedation and analgesia as needed to ensure patient comfort and reduce stress response
Monitor vital signs closely, including oxygen saturation, heart rate, and blood pressure.
Special Considerations And Complications
Difficult Airway:
In anticipated difficult airways, consider awake intubation, use of video laryngoscopy, or a supraglottic airway device
Have a surgical airway kit readily available
Consult with experienced pediatric airway specialists.
Common Complications:
Hypoxemia, esophageal intubation, aspiration, pneumothorax, bradycardia (especially with succinylcholine), prolonged paralysis, vocal cord injury, and dental trauma
Careful technique and correct dosing are essential for prevention.
Neonatal Considerations:
Neonates have different airway anatomy and physiology
Dosing may need to be adjusted based on gestational age and specific clinical context
Apneic oxygenation is particularly important in neonates due to their lower functional residual capacity.
Key Points
Exam Focus:
Weight-based calculations for sedatives and paralytics are critical
Know the preferred agents and their common dosages for pediatric RSI
Recognize contraindications and potential complications.
Clinical Pearls:
Always have your airway cart prepared and equipment checked before starting RSI
Double-check all drug calculations
Use capnography for definitive confirmation of endotracheal tube placement
Apneic oxygenation is a valuable adjunct.
Common Mistakes:
Incorrect weight-based dosing, failure to preoxygenate adequately, delay in administering medications, improper tube placement confirmation, and inadequate post-intubation monitoring.