Rapid-Sequence Intubation of the Pediatric Patient☆,☆☆,★
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.
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.
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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2020, Journal of Pediatric SurgeryPostoperative Tonsillectomy Hemorrhage
2018, Emergency Medicine Clinics of North AmericaCitation Excerpt :The choice of medications for rapid-sequence intubation in the pediatric patient is often institution specific and based on provider comfort level. The authors recommend selecting sedation agents with hemodynamic stability, such as ketamine or etomidate, as post-tonsillectomy hemorrhage can rapidly lead to hypovolemia and the risk of hypotension.41 Paralysis may be achieved with succinylcholine or rocuronium, depending on providers’ comfort and institutional policy.
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2012, Air Medical JournalCitation Excerpt :The use of heliox did not lengthen the time on scene or the total transport time of the critically ill patient. Respiratory compromise is the most common cause of death and severe morbidity in acutely ill children, and nearly 50% of pediatric critical care transports require a respiratory intervention.10 A subset of these transported patients is transported with respiratory symptoms caused by croup.
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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
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Reprint no. 47/1/73347