Each of these steps is discussed in detail in the remainder of the topic. (See "The difficult pediatric airway for emergency medicine", section on 'Identification of the difficult pediatric airway' and "The difficult pediatric airway for emergency medicine", section on 'Management'.)ĪPPROACH - The sequence of steps in pediatric RSI are ( table 1 and table 2): preoxygenation, preparation, administration of pretreatment medications (optional), sedation and paralysis, airway protection and positioning, endotracheal tube placement with confirmation, and postintubation management. For these patients, an alternative plan is warranted, which may involve alternatives such as special airway devices, assistance from subspecialists (anesthesiologists, otorhinolaryngologists, or intensivists), if available, and/or intubation with sedation but without paralysis. However, because sedation and paralysis eliminate protective airway reflexes and spontaneous respiration, RSI must be modified for the patient for whom bag-mask ventilation (BMV) and intubation may be more difficult. PRECAUTIONS - There are no absolute contraindications to RSI. Sedation and paralysis are unnecessary prior to intubation for some patients, such as those who are in cardiac arrest or already deeply comatose. This has been demonstrated in multiple large series of adult patients and several small pediatric series. RSI can be safely performed by emergency physicians trained in advanced airway management, including the use of medications for sedation and paralysis. As an example, in one large, multicenter prospective surveillance study of over 1000 pediatric intubations, RSI was associated with a significantly higher first-past success rate (83 percent) than sedation without paralysis (55 percent). The superiority of RSI, as compared with intubation without sedation and paralysis, has been demonstrated by clinical experience, several small retrospective series, and one large prospective observational series in which success rates for intubation were significantly higher and the incidence of adverse events was significantly lower using RSI in the emergency department. However, up to 80 percent are performed using RSI. In the majority of situations, RSI, from the decision to intubate to successful intubation, is accomplished in less than 10 minutes ( table 2).Įmergency intubations in children can be performed with or without 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.Ī simple, systematic approach to preparation and execution of the procedure is necessary ( table 1 and figure 1). The goal of RSI is to intubate patients quickly and safely using sedation and paralysis. Exceptions include patients who are in cardiac arrest or undergoing sedated intubation without paralysis because of an anticipated difficult airway. We recommend that clinicians who are trained in tracheal intubation use RSI for most children who require emergency intubation. INDICATIONS - RSI provides optimal conditions for emergency intubation. Outside of the operating room, RSI is generally the preferred method for emergency intubation in patients who have varying levels of consciousness and are presumed to have a full stomach, which places them at risk for pulmonary aspiration. Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation. (See "Technique of emergency endotracheal intubation in children" and "The difficult pediatric airway for emergency medicine" and "Supraglottic airway devices in children with difficult airways".)ĭEFINITION - RSI describes a coordinated, sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation. 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 "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis".) The medications commonly used for sedation and paralysis outside of the operating room during RSI in children are discussed separately. INTRODUCTION - This topic will discuss the approach to rapid sequence intubation (RSI) outside of the operating room in children, including the steps involved in performing RSI and the selection of sedative (induction) and paralytic agents according to patient characteristics.
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