UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Rapid sequence intubation (RSI) outside the operating room in children: Approach

Author
Dewesh Agrawal, MD
Section Editor
Susan B Torrey, MD
Deputy Editor
James F Wiley, II, MD, MPH

INTRODUCTION

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".)

DEFINITION

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 [1].

INDICATIONS

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 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.

                    

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Apr 2017. | This topic last updated: May 09, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Gerardi MJ, Sacchetti AD, Cantor RM, et al. Rapid-sequence intubation of the pediatric patient. Pediatric Emergency Medicine Committee of the American College of Emergency Physicians. Ann Emerg Med 1996; 28:55.
  2. Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
  3. Pallin DJ, Dwyer RC, Walls RM, et al. Techniques and Trends, Success Rates, and Adverse Events in Emergency Department Pediatric Intubations: A Report From the National Emergency Airway Registry. Ann Emerg Med 2016; 67:610.
  4. Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med 2002; 23:131.
  5. Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999; 17:141.
  6. Brownstein D, Shugerman R, Cummings P, et al. Prehospital endotracheal intubation of children by paramedics. Ann Emerg Med 1996; 28:34.
  7. Syverud SA, Borron SW, Storer DL, et al. Prehospital use of neuromuscular blocking agents in a helicopter ambulance program. Ann Emerg Med 1988; 17:236.
  8. Gnauck K, Lungo JB, Scalzo A, et al. Emergency intubation of the pediatric medical patient: use of anesthetic agents in the emergency department. Ann Emerg Med 1994; 23:1242.
  9. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
  10. Naguib M, Samarkandi A, Riad W, Alharby SW. Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045.
  11. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151.
  12. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
  13. Marvez-Valls E, Houry D, Ernst AA, et al. Protocol for rapid sequence intubation in pediatric patients -- a four-year study. Med Sci Monit 2002; 8:CR229.
  14. Moynihan RJ, Brock-Utne JG, Archer JH, et al. The effect of cricoid pressure on preventing gastric insufflation in infants and children. Anesthesiology 1993; 78:652.
  15. Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979.
  16. Luten RC, Kissoon N. Approach to the pediatric airway. In: Manual of Emergency Airway Management, Walls RM, Murphy MF, Luten RC, et al (Eds), Lippincott Williams and Wilkins, Philadelphia 2004. p.212.
  17. Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth 1994; 41:771.
  18. Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance and atropine. Arch Dis Child 2012; 97:139.
  19. Kelly MA, Finer NN. Nasotracheal intubation in the neonate: physiologic responses and effects of atropine and pancuronium. J Pediatr 1984; 105:303.
  20. Oei J, Hari R, Butha T, Lui K. Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial. J Paediatr Child Health 2002; 38:146.
  21. Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care 2004; 20:651.
  22. Jones P, Dauger S, Denjoy I, et al. The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations. Pediatr Crit Care Med 2013; 14:e289.
  23. Kleinman ME, de Caen AR, Chameides L, et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261.
  24. Tsou CH, Chiang CE, Kao T, et al. Atropine-triggered idiopathic ventricular tachycardia in an asymptomatic pediatric patient. Can J Anaesth 2004; 51:856.
  25. Moritz HA, Parnass SM, Mitchell JS. Ventricular fibrillation during anesthetic induction in a child with undiagnosed mitral valve prolapse. Anesth Analg 1997; 85:59.
  26. Jones P. The therapeutic value of atropine for critical care intubation. Arch Dis Child 2016; 101:77.
  27. LEIGH MD, McCOY DD, BELTON MK, LEWIS GB Jr. Bradycardia following intravenous administration of succinylcholine chloride to infants and children. Anesthesiology 1957; 18:698.
  28. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary and Emergency Cardiovascular Care - Part 12. Pediatric advanced life support. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-12-pediatric-advanced-life-support/ (Accessed on November 10, 2015).
  29. de Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S526.
  30. Zelicof-Paul A, Smith-Lockridge A, Schnadower D, et al. Controversies in rapid sequence intubation in children. Curr Opin Pediatr 2005; 17:355.