Rapid sequence intubation in children: Rapid overview of emergency management

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% FiO₂ (>7 L/min oxygen flow) by nonrebreather mask for 3 minutes
Apneic or inadequate breathing: Bag-mask ventilation with small tidal breaths using 100% FiO₂
During induction and paralysis, provide apneic oxygenation via nasal cannula at flow rate of 1 L/kg/min (maximum flow 15 L/min)

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 1 mg; if no IV access, can be given IM).

Induction (sedation)

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.

Paralytic

Rocuronium:

Use for children with contraindication for succinylcholine or as primary paralytic if sugammadex is immediately available.
Dose: 1 mg/kg IV.*

Succinylcholine:

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 mg/kg IV (if IV access unobtainable, can be given IM, dose: 4 mg/kg)^¶.

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.^Δ

Positioning, with placement

Confirm tracheal tube placement with end-tidal CO₂ 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; CO₂: carbon dioxide; FiO₂: fraction of inspired oxygen.

* 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.

¶ 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 IM 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.

Δ 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 UpToDate 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)

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Rapid sequence intubation in children: Rapid overview of emergency management