children adult
Rapid overview of rapid sequence intubation in children
Preparation – Utilize an active checklist to:
o Begin preoxygenation as described below.
o 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).
o Identify conditions that will predict difficult intubation or bag-mask ventilation (eg. Small chin, inability to fully open mouth, upper airway trauma, or infection).
o Assemble equipment and check for function.
o 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:
o Spontaneously breathing: 100% FiO2 (>7 L/min oxygen flow) by nonrebreather mask for 3 minutes
o Apneic or inadequate breathing: Bag-mask ventilation with small tidal breaths using 100% FiO2
o 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:
o Children </= 1 year
o Children in shock
o Children <5 years receiving succinylcholine
o 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 10mg; 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: 1mg/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 hypertherma; 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, does 4mg/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 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 CO2 detection and auscultation.
Postintubation management
Obtain a chest radiograph to confirm the depth of the tracheal tube insertion.
Provide ongoing sedation (eg. Midazolam), analgesia (eg. Fentanyl 1mcg/kg), and, if indicated, paralysis.
