Rapid-Sequence Intubation of the Pediatric Patient,☆☆,

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Abstract

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children. [Gerardi MJ, Sacchetti AD, Cantor RM, Santamaria JP, Gausche M, Lucid W, Foltin GL: Rapid-sequence intubation of the pediatric patient. Ann Emerg Med July 1996;28:55-74.]

See related editorial, Rapid-Sequence Intubation Comes of Age

Section snippets

INTRODUCTION

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Pediatric emergency endotracheal intubation (ETI) is a lifesaving technique with which all emergency physicians should be familiar.1, 2, 3, 4, 5 Poor airway visualization, distorted anatomy, limited pretreatment, gastric distention, or cardiovascular instability may make ETI difficult and hazardous. Adverse effects of the intubation procedure itself include intracranial pressure (ICP)

INDICATIONS

RSI is used in patients requiring immediate ETI. The major advantage of this technique is the elimination of resistance to direct laryngoscopy. RSI also addresses the foreign body reflexes initiated by introduction of an endotracheal tube into the trachea. Figure 1 lists common indications and relative contraindications for the use of RSI.

. Indications for and relative contraindications to RSI.

There is no advantage in using RSI in a patient with cardiac arrest or a deeply comatose patient with no

RAPID-SEQUENCE INTUBATION

RSI comprises a series of steps designed to minimize adverse physiologic responses and maximize successful endotracheal intubation (Figure 2). These steps include rapid sedation and paralysis while oxygenation is maintained and adjunctive measures are performed to protect the patient from aspiration (Figure 3). Many of the steps that follow can be done simultaneously by different personnel, but the entire sequence should be directed by one physician.

. RSI.

. RSI: The steps.

Step 1: Brief history and

FAILED INTUBATION

Any clinician involved in pediatric airway management must be prepared to manage the child in whom ETI cannot be readily accomplished. After paralysis, an intubation attempt should be continued as long as the patient remains oxygenated. Continuous pulse oximetry should be used to determine when arterial desaturation is beginning. Depending on the success of preoxygenation techniques, this point may be anywhere from 30 seconds to 4 minutes. After a failed attempt the patient should be ventilated

PROTOCOLS

In extreme conditions, RSI may be performed by simply bolus-dosing a patient with a paralytic and a sedative agent before intubation. If time permits, a more organized RSI protocol may be used to permit better physiologic control during the procedure. The entire procedure, from the decision to intubate to completion of the procedure, should take less than 5 minutes. Depending on the circumstances, the time for the steps may be shortened and the intubation completed in less than 3 minutes. If

CONCLUSION

RSI is an essential skill for physicians who manage critically ill or injured children. Its responsible use by emergency physicians should be encouraged as the optimal method for intubation in awake or resistive children.

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    From the Saint Barnabas Medical Center, Livingston, New Jersey*; Our Lady of Lourdes Medical Center, Camden, New Jersey, SUNY Health Science Center, Syracuse, New York§; St Joseph's Hospital, Tampa, Florida; Harbor–UCLA Medical Center, Torrance, California; Good Samaritan Medical Center, Phoenix, Arizona#; and Bellevue Hospital Center, New York, New York.**

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    Address for reprints: American College of Emergency Physicians, Sales and Service, PO Box 619911, Dallas, Texas 75261-9911, 800-798-1822 ext 6, Available electronically from www.acep.org

    Reprint no. 47/1/73347

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