Saturday, March 16, 2013

Pediatric Critical Care: Rapid Sequence Intubation Steps

One of the necessity to secure airway during a Pediatric emergency is accomplised by the RSI , Rapid Sequence Intubation.
Stabilizing airway becomes the most important thing in a child with low GCS.
Intubation will be required in a child who cannot maintain oxygenation, who cannot maintain airway or has risk of aspiration.


 1 Obtain a brief history and perform an assessment Rule out drug allergies; examine the airway anatomy (e.g., micrognathia, cleft palate)
 2 Assemble equipment, medications, etc. See lists below
 3 Preoxygenate the patient With bag/mask, nasal cannula, hood or blow-by
 4 Premedicate the patient with lidocaine, atropine Lidocaine minimizes the ICP rise with intubation and can be applied topically to the airway mucosa for local anesthesia
Atropine helps blunt the bradycardia associated with upper airway manipulation and reduces airway secretions
 5 Induce sedation and analgesia Sedatives:
 Thiopental (2-5 mg/kg): Very rapid onset; can cause hypotension.
 Diazepam (0.1 mg/kg): Onset 2-5 min; elimination in 30-60 min or more.
 Ketamine (2 mg/kg): Onset 1-2 min; elimination in 30-40 min. May cause hallucinations if used alone; causes higher ICP, mucous secretions, increased vital signs, and bronchodilation.
 Fentanyl (3-10 ?g/kg, may repeat 3-4?): Rapid administration risks “tight chest” response, with no effective ventilation. Effects wear off in 20-30 min.
 Morphine (0.05-0.1 mg/kg dose): May last 30-60 min; may lead to hypotension in hypovolemic patients.
 6 Pretreat with nondepolarizing paralytic agent Small dose of a nondepolarizing paralytic agent (see below), with intent of diminishing the depolarizing effect of succinylcholine, which is administered next
 7 Administer muscle relaxants Succinylcholine dose is 1-2 mg/kg; causes initial contraction of muscles, then relaxation. This depolarization can, however, raise ICP and blood pressure. Onset of paralysis in 30-40 sec; duration is 5-10 min.
Increased use of pretreatment with a nondepolarizing muscle relaxant, especially rocuronium (1 mg/kg), which has a very rapid onset and short duration. Other nondepolarizing agents include vecuronium and pancuronium, both dosed at 0.1 mg/kg.
 8 Perform a Sellick maneuver Pressure on the cricoid cartilage, to occlude the esophagus and prevent regurgitation or aspiration
 9 Perform endotracheal intubation ET: Select the proper size for the age and weight of the child
Laryngoscope blades: A variety of Miller and the Macintosh blades
Patient supine; the neck is extended moderately to the “sniffing” position
10 Secure the tube and verify the position with a roentgenogram ET secured with tape to the cheeks and upper lip or to an adhesive patch applied to the skin near the mouth.
11 Begin mechanical ventilation Verify tube placement before ventilating with positive pressure; if an ET tube is in one bronchus, barotraumas may occur

VIDEO demonstartion of Intubation: Intubation Procedure video

Intubation Procedure
Extracted From Nelson Text Book of Pediatrics 19th edition