Rapid sequence intubation (RSI) outside the operating room in children: Approach
- Dewesh Agrawal, MD
Dewesh Agrawal, MD
- Associate Professor of Pediatrics and Emergency Medicine
- Children's National Medical Center
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Pediatric Emergency Medicine
- Texas Children’s Hospital
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will discuss the approach to RSI outside of the operating room in children, including the steps involved in performing RSI and the selection of sedative and paralytic agents according to patient characteristics. The medications commonly used for sedation and paralysis outside of the operating room during RSI in children are discussed separately. (See "Rapid sequence intubation (RSI) outside of the operating room in children: Medications for sedation and paralysis".)
Procedures for pediatric laryngoscopy and intubation and the approach to the difficult pediatric airway, including rescue devices when endotracheal intubation is challenging are also discussed separately. (See "Emergency endotracheal intubation in children" and "The difficult pediatric airway" and "Emergency rescue devices for difficult pediatric airway management".)
RSI describes a sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation. Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
Outside of the operating room, RSI is generally the preferred method for emergently intubating patients who have varying levels of consciousness and are presumed to have a full stomach .
RSI provides optimal conditions for emergent intubation. We recommend that clinicians who are trained in tracheal intubation use RSI for most children who require emergent intubation and who are not in cardiac arrest or already deeply comatose. The goal of RSI is to intubate patients quickly and safely using sedation and paralysis. RSI is generally recommended because it is more successful and safer than intubation without sedation and paralysis for patients with varying levels of consciousness, active protective airway reflexes, and/or a full stomach.
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- - Assessment
- Focused history
- Physical examination
- - Intubation treatment plan
- - Equipment and monitoring
- Sedation with paralysis
- - Selection of sedative agent
- - Selection of paralytic agent
- - Positioning for intubation
- External laryngeal manipulation (bimanual laryngoscopy)
- Cricoid pressure
- Placement, with confirmation
- Postintubation management
- SUMMARY AND RECOMMENDATIONS