What is the recommended approach for pediatric Rapid Sequence Intubation (RSI)?

Pediatric Rapid Sequence Intubation

Medication Protocol

For pediatric RSI, administer atropine pretreatment (0.01-0.02 mg/kg IV) in children 28 days to 8 years old, followed by ketamine (1-2 mg/kg IV) as the induction agent, and succinylcholine as the first-line neuromuscular blocker (dose varies by age: 1.8 mg/kg for neonates <1 month, 2.0 mg/kg for infants 1 month-1 year, 1.2 mg/kg for children 1-10 years, and 1-1.5 mg/kg for children >10 years). 1, 2

Pretreatment Phase

Atropine administration is mandatory for specific pediatric populations:

• Give atropine 0.01-0.02 mg/kg IV (maximum 0.5 mg) to all children aged 28 days to 8 years, particularly those with septic shock, hypovolemia, or when using succinylcholine 1, 2
• This prevents bradycardia during laryngoscopy and from succinylcholine-induced vagal stimulation 1
• For patients with elevated intracranial pressure, consider lidocaine 1-2 mg/kg IV administered 30 seconds to 5 minutes before airway instrumentation 1, 2

Induction Agent Selection

Ketamine is the preferred first-line sedative-hypnotic agent:

• Dose ketamine at 1-2 mg/kg IV for most pediatric RSI scenarios 1, 2
• Alternative dosing: 3-4 mg/kg for infants <18 months; 2 mg/kg for children ≥18 months 2
• Ketamine maintains hemodynamic stability through sympathomimetic effects, making it ideal for hemodynamically unstable patients 1, 2
• This agent is strongly preferred over etomidate in septic shock due to adrenal suppression concerns with etomidate 3, 2

Etomidate is an alternative option with specific indications:

• Dose etomidate at 0.2-0.4 mg/kg IV (maximum 20 mg) 1, 2
• Use etomidate preferentially in children >2 years old with head injury, as it lowers intracranial pressure 1
• Avoid etomidate in septic patients due to adrenal suppression risk 2
• Etomidate has minimal hemodynamic effects but should not be used in sepsis 1

Neuromuscular Blocking Agent Selection

Succinylcholine remains the first-line paralytic:

• Use succinylcholine for children with respiratory or cardiovascular compromise 4, 1, 2
• Age-specific dosing is critical:
  • Neonates <1 month: 1.8 mg/kg IV 1, 2
  • Infants 1 month to 1 year: 2.0 mg/kg IV 1, 2
  • Children 1-10 years: 1.2 mg/kg IV 4, 1, 2
  • Children >10 years: 1-1.5 mg/kg IV 1, 2
• Succinylcholine provides rapid onset and short duration, making it ideal for emergency situations 4

Rocuronium is the alternative when succinylcholine is contraindicated:

• Dose rocuronium at 0.9-1.2 mg/kg IV 4, 1, 2
• Use rocuronium when succinylcholine is contraindicated (hyperkalemia risk, neuromuscular disease, malignant hyperthermia history) 4
• Sugammadex must be immediately available when using rocuronium for potential reversal in a "can't intubate, can't ventilate" scenario 4, 1, 2
• The choice between succinylcholine and rocuronium should consider desired duration of paralysis, risk of difficult intubation, and presence of neuromuscular disease 4

Equipment and Monitoring Considerations

Videolaryngoscopy should be considered in specific scenarios:

• Use videolaryngoscopy as first option for anticipated difficult intubation with possible mask ventilation 4
• Consider videolaryngoscopy after failed direct laryngoscopy to increase success rates 4
• In children with prior difficult intubation history, videolaryngoscopy can be chosen as first-line 4

Essential monitoring and preparation:

• Personnel with advanced airway management skills must be present when administering neuromuscular blockers 2
• Age-appropriate equipment for aspiration, oxygenation, intubation, and ventilation must be immediately available 2
• Continuous oxygen saturation monitoring is mandatory 2

Critical Pitfalls to Avoid

Common errors that increase morbidity:

• Failure to administer atropine in young children (<8 years), especially with succinylcholine use, significantly increases risk of clinically significant bradycardia 1, 2
• Using succinylcholine in patients with hyperkalemia risk (crush injuries, burns >24 hours old, denervation injuries, neuromuscular disease) can cause cardiac arrest 1
• Proceeding with rocuronium without immediately available sugammadex creates unnecessary risk in failed airway scenarios 4, 1
• Using ketamine-only approach (without neuromuscular blocker) results in significantly lower first-pass success (61%) compared to proper RSI (90%) and higher complication rates 5
• Attempting intubation without muscle relaxation is not recommended, as muscle relaxation significantly improves intubation conditions 4

Clinical Success Data

RSI demonstrates superior outcomes in pediatric patients:

• RSI achieves 78% first-attempt success compared to 47% without medications and 44% with sedation alone 6
• Overall success rate with RSI reaches 99% in pediatric emergency department intubations 6
• True complications occur in only 1% of RSI attempts versus 5% with no medications 6
• The majority of pediatric emergency intubations (81%) utilize RSI as the preferred method 6