Pediatric Rapid Sequence Intubation
Medication Regimen Overview
For pediatric RSI, administer atropine pretreatment (for children 28 days to 8 years), followed by ketamine as the first-line induction agent (1-2 mg/kg IV), and succinylcholine as the first-line neuromuscular blocker (age-adjusted dosing), with rocuronium (0.9-1.2 mg/kg IV) reserved for when succinylcholine is contraindicated. 1, 2
Step 1: Pretreatment with Atropine
Atropine is mandatory for children aged 28 days to 8 years to prevent bradycardia during laryngoscopy and from succinylcholine administration. 1, 2
- Dosing: 0.01-0.02 mg/kg IV (maximum 0.5 mg) 1, 2
- Timing: Administer during induction and before intubation 1
- Especially critical in: Children with septic shock, hypovolemia, or when succinylcholine will be used 1, 2
Common pitfall: Failure to administer atropine in young children increases the risk of clinically significant bradycardia, particularly with succinylcholine use. 1
Optional Pretreatment for Elevated ICP
- Lidocaine 1-2 mg/kg IV may be considered 30 seconds to 5 minutes before airway instrumentation in patients with increased intracranial pressure, though evidence is low quality. 1, 2
Step 2: Induction Agent Selection
First-Line: Ketamine
Ketamine is the preferred first-line induction agent for pediatric RSI, especially in hemodynamically unstable patients. 1, 2
- Dosing: 1-2 mg/kg IV 1, 2
- Alternative dosing by age: 3-4 mg/kg before 18 months; 2 mg/kg after 18 months 2
- Advantages: Maintains hemodynamic stability through sympathomimetic effects 1
- Preferred scenarios: Hemodynamically unstable patients, respiratory compromise 1, 2
Caveat: In critically ill patients with depleted catecholamine stores, ketamine may paradoxically cause hypotension despite its sympathomimetic properties. 3
Alternative: Etomidate
Etomidate is an alternative first-line agent, particularly useful in patients with head injury. 1
- Dosing: 0.2-0.4 mg/kg IV (maximum 20 mg) 1, 2
- Advantages: Minimal hemodynamic effects, lowers intracranial pressure 1
- Age consideration: First-choice in children over 2 years old, except in sepsis 2
- Important contraindication: Pediatric guidelines explicitly recommend against etomidate in septic shock due to adrenal suppression concerns. 3
Step 3: Neuromuscular Blocking Agent Selection
First-Line: Succinylcholine
Succinylcholine is the first-line neuromuscular blocker for pediatric RSI in patients with respiratory or cardiovascular compromise. 4, 1, 2
Age-Adjusted Dosing:
- >10 years: 1-1.5 mg/kg IV 1, 2
- 1-10 years: 1.2 mg/kg IV 4, 1, 2
- 1 month to 1 year: 2.0 mg/kg IV 4, 1, 2
- <1 month (neonates): 1.8 mg/kg IV 1, 2
Rationale: Succinylcholine provides rapid onset and short duration, making it ideal for RSI when no contraindications exist. 4
Critical pitfall: Using succinylcholine in patients with contraindications such as hyperkalemia can lead to cardiac arrest. 1
Alternative: Rocuronium
Rocuronium should be used when succinylcholine is contraindicated. 4, 1, 2
- Dosing: 0.9-1.2 mg/kg IV (doses >0.9 mg/kg recommended) 4, 1, 2, 5
- Onset: Provides excellent intubating conditions within 60-75 seconds at appropriate doses 5
- Duration consideration: Longer duration of action than succinylcholine must be weighed against succinylcholine's side effect risks 4
Essential safety measure: Sugammadex must be rapidly available when rocuronium is used for potential reversal in a "can't intubate, can't ventilate" scenario. 4, 1, 2
Important note: Rocuronium is NOT recommended for rapid sequence intubation in pediatric patients according to FDA labeling, though clinical guidelines support its use as an alternative to succinylcholine. 5
Step 4: Equipment and Monitoring Requirements
- Personnel with airway management skills must be present when neuromuscular blockers are administered 2
- Age-appropriate equipment for aspiration, oxygenation, intubation, and ventilation must be immediately available 2
- Continuous oxygen saturation monitoring is required 2
- Peripheral nerve stimulator should be available to confirm adequate blockade before intubation attempt 3
Step 5: Videolaryngoscopy Consideration
Videolaryngoscopy should be used as first option for patients with anticipated difficult intubation but possible mask ventilation, or after failure of direct laryngoscopy. 4
- Videolaryngoscopy improves glottic vision and increases first-attempt success rates in children with difficult airway criteria 4
- External laryngeal maneuvers are facilitated when using videolaryngoscopy with a remote screen 4
Clinical Outcomes and Success Rates
- RSI demonstrates superior first-attempt success (78%) compared to intubation without medications (47%) or sedation alone (44%) in pediatric emergency department patients 6
- Overall success rate with RSI: 99% in pediatric emergency intubations 6
- Complication rate with RSI: Only 1% true complications in pediatric emergency department RSI 6
- Ketamine-only approach (without paralytic) is NOT recommended: Associated with only 61% first-attempt success and 32% adverse event rate, significantly worse than standard RSI 7
Common Pitfalls to Avoid
- Omitting atropine in young children (28 days to 8 years), particularly when using succinylcholine 1, 2
- Using succinylcholine in patients with hyperkalemia risk (burns, crush injuries, neuromuscular disease) 1
- Failing to have sugammadex immediately available when using high-dose rocuronium 1, 2
- Using etomidate in septic patients due to adrenal suppression concerns 3, 2
- Attempting intubation before full neuromuscular blockade is achieved (wait at least 60 seconds after rocuronium) 3