Rapid sequence intubation (RSI) in children for emergency medicine: Approach

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. The medications commonly used for sedation and paralysis outside of the operating room during RSI in children are discussed separately. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis".)

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 "Technique of emergency endotracheal intubation in children" and "The difficult pediatric airway for emergency medicine" and "Supraglottic airway devices in children with difficult airways".)

DEFINITION — RSI describes a coordinated, sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation. Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal 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 [1].

INDICATIONS — RSI provides optimal conditions for emergency intubation. We recommend that clinicians who are trained in tracheal intubation use RSI for most children who require emergency intubation. Exceptions include patients who are in cardiac arrest or undergoing sedated intubation without paralysis because of an anticipated difficult airway. The goal of RSI is to intubate patients quickly and safely using 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.

A simple, systematic approach to preparation and execution of the procedure is necessary (table 1 and figure 1). In the majority of situations, RSI, from the decision to intubate to successful intubation, is accomplished in less than 10 minutes (table 2).

Emergency intubations in children can be performed with or without sedation and paralysis. However, up to 80 percent are performed using RSI [2,3]. 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 [2-9]. 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) [3].

RSI can be safely performed by emergency physicians trained in advanced airway management, including the use of medications for sedation and paralysis. This has been demonstrated in multiple large series of adult patients and several small pediatric series [2,8-11].

Sedation and paralysis are unnecessary prior to intubation for some patients, such as those who are in cardiac arrest or already deeply comatose.

PRECAUTIONS — There are no absolute contraindications to RSI. 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. 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. (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'.)

APPROACH — 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. Each of these steps is discussed in detail in the remainder of the topic.

Infection control precautions — For children with suspected highly contagious and virulent airborne pathogens such as early COVID-19 variants prior to the availability of effective vaccines, there is a significant risk for transmission during laryngoscopy, endotracheal intubation, and other airway management procedures. Techniques designed to improve patient care, minimize infectious risks to care providers, and decrease spread of pathogens should be applied to all such children undergoing rapid sequence intubation. The following measures are adapted from consensus guidance for advanced life support [12]:

●All personnel involved with the procedure should wear personal protective equipment including an N95 mask, eye protection, gown, and gloves.

●Whenever possible, perform RSI in a negative pressure room or room with a portable HEPA filtration unit.

●Use an inline HEPA filter during bag ventilation.

●Assure appropriately experienced practitioners manage the airway to reduce unnecessary risks of exposure and transmission.

●Oral intubation with a cuffed endotracheal tube is preferred to nasal intubation.

●A supraglottic airway (SGA) with a good seal is an acceptable method for securing the airway as a temporizing or rescue measure.

●Because of higher first-attempt success in patients with difficult airways, video laryngoscopy is preferred to direct laryngoscopy.

●Use an in-line HEPA filter and adapters for suctioning/bronchoscopy during mechanical ventilation.

Health care providers can significantly reduce their risk of infection, especially severe infection and death, by receiving recommended vaccinations.

Preparation — In the preparation phase of RSI, a treatment plan for intubation based upon the patient's clinical condition must be quickly developed. This is done as the patient is being preoxygenated.

We support the active use of intubation checklists that are customized to the setting and include items on patient assessment, required equipment, and medications as a means to reduce the frequency of errors during RSI (figure 1).

A rapid review of key aspects of the child's history, as well as a targeted physical examination, helps identify conditions that affect the optimal choices of medications for pretreatment, sedation, paralysis, and postintubation management, as well as a contingency plan in the event of a failed intubation. In addition, equipment for monitoring and airway management should be assembled and its function checked. (See "Technique of emergency endotracheal intubation in children", section on 'Materials, equipment, and personnel'.)

Assessment — A rapid review of key aspects of the child's history, as well as a targeted physical examination, must identify the following conditions:

●Preexisting or current conditions that may be adversely affected by medications, airway manipulation, or positive-pressure ventilation (particularly cardiovascular compromise, tamponade physiology, increased intracranial pressure [ICP], bronchospasm, and, if succinylcholine use is planned, presence of contraindications as listed below) (see 'Focused history' below)

●Clinical features that may make bag-mask ventilation (BMV), laryngoscopy, and/or tracheal intubation difficult (table 3 and table 4) (see "The difficult pediatric airway for emergency medicine", section on 'Identification of the difficult pediatric airway')

Focused history — The following historical information is useful for selecting medications for RSI, as well as anticipating possible difficulties with airway or ventilation.

●Previous difficulty with intubation.

●Previous adverse effects from anesthesia.

●If succinylcholine use is planned, absolute contraindications for the use of succinylcholine:

•Chronic myopathy (eg, Becker or Duchenne muscular dystrophy)

•Denervating neuromuscular disease (eg, cerebral palsy with paralysis)

•More than 48 to 72 hours after burns, multiple trauma, or an acute denervating event (eg, stroke or spinal cord injury)

•Extensive crush injury with rhabdomyolysis

•History of malignant hyperthermia in patient or family

•Significant hyperkalemia (eg, suggested by characteristic changes on electrocardiogram)

●History of asthma – Laryngoscopy may precipitate bronchospasm in children with asthma. In addition, patients with bronchospasm may be difficult to ventilate.

●Noisy breathing, particularly in sleep – This history suggests some degree of anatomic upper airway obstruction (such as enlarged tonsils or tongue) that may interfere with laryngoscopy or BMV.

●Allergies to medications.

Physical examination — Evidence of the following conditions will influence the choice of medications for pretreatment, sedation (induction), and paralysis (see 'Selection of sedation (induction) agent' below and 'Selection of paralytic agent' below):

●Hemodynamic instability suggested by tachycardia, poor peripheral perfusion, or hypotension

●Increased ICP, including altered mental status or focal neurologic signs

●Bronchospasm

●Status epilepticus

●Any condition that is a contraindication to using succinylcholine

Problems with effective BMV or difficult laryngoscopy and intubation can occur in children with certain physical features. These features include the following (table 3 and table 4) (see "The difficult pediatric airway for emergency medicine", section on 'Identification of the difficult pediatric airway'):

●Hoarseness, stridor, drooling, or an upright position of comfort ("tripod" or "sniffing" position) indicates the presence of upper airway obstruction. (See "Emergency evaluation of acute upper airway obstruction in children", section on 'Determining the cause of upper airway obstruction'.)

●A child with a prominent occiput or misshapen head may be difficult to position optimally for BMV or laryngoscopy.

●Facial anomalies, burns, or other trauma can make it difficult to obtain an adequate seal for BMV. (See "Basic airway management in children".)

●Small mouth, abnormal palate, large tongue, or a small mandible all suggest that laryngoscopy will be difficult because of decreased space within the oral cavity and mandible.

●Short neck or poor mobility of the neck (congenital anomaly, cervical spine immobilization) may interfere with positioning of the head and neck.

Intubation treatment plan — In addition to choosing medications, an intubation treatment plan should include the following:

●Medications for pretreatment, sedation, paralysis, and postintubation management should be drawn up in weight- or length-based doses, doses verified, and syringes carefully labeled.

●A contingency plan for failed intubation must be delineated when a difficult airway is anticipated. Specialized equipment should be immediately available (eg, gum elastic bougie, supraglottic airway [laryngeal mask airway, if not contraindicated by upper airway anatomic distortion], and a video laryngoscope). (See "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Intubating introducers (gum elastic bougie)' and "Supraglottic airway devices in children with difficult airways" and "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Video laryngoscope'.)

Emergency involvement of additional airway specialists (eg, anesthesiologist, intensivist, and otolaryngologist) should occur whenever possible when a difficult airway is expected. (See "The difficult pediatric airway for emergency medicine", section on 'Management'.)

●Roles should be clearly assigned to each health care provider, including an assistant to the intubator and someone to maintain external laryngeal manipulation (ELM) or, in young infants, cricoid pressure. (See 'External laryngeal manipulation (bimanual laryngoscopy)' below.)

Equipment and monitoring — No medications for sedation (induction) or paralysis should be administered until all necessary personnel, monitoring, and equipment are present and ready. An example of a checklist for RSI in children is provided (figure 1).

The equipment and monitoring that are necessary for children receiving RSI are the same as for any patient requiring advanced airway management:

●Monitoring of oxygen saturation, heart rate, respiratory rate, blood pressure, and end-tidal carbon dioxide (EtCO₂) detection

●At least one, and preferably two functioning intravenous (IV) lines

●Tested and functioning suction (Yankauer and flexible catheter) and airway equipment

The endotracheal tube size for children can be estimated based upon age (table 5) (calculator 1). Beyond the newborn period, cuffed endotracheal tubes are equally as safe as uncuffed tubes. When using cuffed tubes, care must be taken to monitor and limit cuff pressures to <20 to 25 cm H₂O to avoid the risk of tracheal mucosal ischemia. (See "Technique of emergency endotracheal intubation in children", section on 'Endotracheal tube'.)

Preoxygenation — Preoxygenation with 100 percent inspired oxygen should begin as soon as possible once the need for endotracheal intubation becomes evident:

●Spontaneously breathing patients – Apply a nonrebreather mask for a minimum of three minutes. From a practical viewpoint, oxygen should be administered at the highest concentration available as soon as RSI is potentially needed.

●Apneic or inadequately breathing patients – Perform careful BMV with small tidal volumes and 100 percent oxygen at a flow rate >7 L/minute with the goals of achieving an oxygen saturation of 100 percent or as high as possible and filling the residual capacity of the lungs with oxygen (typically one to two minutes). Limited evidence suggests that cricoid pressure during BMV may prevent gastric insufflation, which reduces the risk of regurgitation and aspiration. Its use is optional during BMV [13]. (See 'Protection' below and "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Positioning and protection'.)

●During sedation (induction) and paralysis – Provide apneic oxygenation via nasal cannula at a flow rate of 1 L/kg per year of age (maximum 15 L/minute) to extend the period of adequate oxygen saturation.

The benefit of apneic oxygenation in children is unclear. For example, in a retrospective, observational study of almost 150 children undergoing intubation in an emergency department, apneic oxygenation was associated with a significant reduction in hypoxemia (pulse oximetry <90 percent) during endotracheal intubation versus no apneic oxygenation and a significantly higher median oxygen saturation during endotracheal intubation (100 versus 93 percent) [14]. In a prospective, single-center, observational study of nearly 1400 endotracheal intubations in a pediatric intensive care unit, the implementation of routine apneic oxygenation during endotracheal intubation was associated with a decrease in both moderate (15 versus 12 percent) and severe (10 versus 7 percent) oxygen desaturation [15]. Apneic oxygenation has also been shown to extend the safe apnea time in adult trials. However, in a separate retrospective, observational study of 305 children undergoing RSI in the emergency department, apneic oxygenation was not associated with a lower rate or lesser degree of oxygen desaturation compared with standard preoxygenation [16]. Nevertheless, apneic oxygenation has little risk, although, in our experience, a nasal cannula may occasionally limit the ability to achieve a good mask seal in the event that the patient requires BMV. (See "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Adjunct strategies to maximize preoxygenation'.)

Preoxygenation establishes a reservoir of oxygen within the lungs as well as an oxygen surplus throughout the body. The patient can then tolerate longer periods of apnea without oxygen desaturation, permitting intubation to proceed without BMV [17].

Preoxygenation is particularly important for infants and children. Compared with adults, young patients have a higher oxygen consumption rate with lower functional residual capacity and alveolar volume [18,19]. Consequently, oxygen desaturation occurs much more rapidly [17,18]. As an example, arterial oxygen desaturation to 80 percent may occur in a preoxygenated, apneic, healthy 10-kg infant in less than four minutes, as compared with over eight minutes in a healthy 70-kg adult.

Pretreatment — Pretreatment medications are optional for selected patients as described below.

RSI becomes more complex and takes longer with the addition of each medication. Consequently, the decision of whether or not to use additional agents must include consideration of the potential benefit to the patient, as well as possible adverse consequences of a prolonged procedure or unanticipated drug responses. In general, pretreatment medications are used less often than in the past. As an example, in one multicenter, prospective observational study that evaluated the use of pretreatment medications over 10 years (2002 to 2012), the use of any pretreatment medication (eg, atropine, lidocaine, fentanyl, or defasciculating doses of neuromuscular blocking agents) fell to <30 percent of intubations by the end of the study [3].

Despite this trend, certain patients may potentially beneficial from pretreatment medications prior to RSI as follows:

●Infants younger than one year of age – Although atropine is not routinely recommended for pretreatment prior to endotracheal intubation, we frequently use it for pretreatment during RSI for infants younger than one year of age because of their predilection for vagally induced bradycardia. If used, the dose of atropine for pretreatment during RSI is 0.02 mg/kg (maximum 1 mg) IV without a minimum dose. (See "Primary drugs in pediatric resuscitation", section on 'Atropine'.)

Infants and young children may have a pronounced vagal response (eg, bradycardia with poor perfusion) to laryngoscopy, which, in healthy patients, will typically resolve with oxygenation and cessation of laryngoscopy and is not associated with poor outcomes [20]. However, in our experience, bradycardia may limit the duration of laryngoscopy and prevent prompt securing of the airway in a critically ill infant or child. Observational studies in infants and children and small trials in critically ill neonates suggest that pretreatment with atropine limits or prevents bradycardia without inducing ventricular arrhythmias [21-24].

However, atropine may hamper the ability to assess the patient's oxygenation, heart rate, and neurologic status:

•The effect of atropine on heart rate may persist for several hours [25]. Atropine may also prevent the bradycardic response to hypoxemia [26]. Patients should be monitored for hypoxemia with pulse oximetry during and after endotracheal intubation.

•Atropine dilates the pupils, although it does not eliminate pupil constriction in response to light. However, it may still complicate the ability to evaluate a change in neurologic status once the patient is paralyzed. (See "Primary drugs in pediatric resuscitation", section on 'Atropine'.)

By contrast, rare cases of ventricular tachycardia and fibrillation after atropine pretreatment in children undergoing routine anesthesia have been reported [27,28]. In that setting, atropine is no longer routinely used.

●Infants and children with signs of septic shock or late stage hypovolemic shock – Although evidence is lacking, atropine may be beneficial for children with septic shock or late-stage hypovolemia because it may prevent progressive unstable bradycardia by counteracting reflex bradycardia [20,29].

●Patients receiving succinylcholine for paralysis – Administration of succinylcholine has been associated with bradycardia and asystole in children [20,26,30]. Although some experts question the need for atropine when a single dose of succinylcholine is used in children [26], atropine has long been used as a pretreatment to counteract these effects, and the American Heart Association guidelines indicate that atropine pretreatment is appropriate for patients undergoing muscle paralysis with succinylcholine as follows [31,32]:

•Children five years of age or younger who are receiving succinylcholine

•Children older than five years of age who are receiving a second dose of succinylcholine

Defasciculating agents (eg, rocuronium or vecuronium at one-tenth of the paralyzing dose) are not routinely recommended for children receiving succinylcholine.

●Patients with suspected increased intracranial pressure — Evidence is lacking to show that lidocaine or ultra-short-acting opioids (eg, fentanyl) improves upon neuroprotection provided by commonly used sedatives (induction agents) in children with suspected increased intracranial pressure who are undergoing RSI. Sedation (induction) agents for RSI in these patients are discussed in greater detail separately. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Airway'.)

Sedation (induction) with paralysis — A sedative for induction and a paralytic are the two essential medications used in RSI. The sedation agent must always be administered first, followed rapidly by a paralytic once the child becomes unconscious.

Route of administration — The IV route is strongly preferred for all medications used during RSI. When IV access is not possible, administration through an intraosseous line is a reasonable alternative.

On rare occasions, it may be necessary to intubate a patient for whom neither IV nor intraosseous access is possible. In these circumstances, the patient may receive succinylcholine, 4 mg/kg intramuscularly (IM), maximum dose 150 mg, if not contraindicated, along with a sedation (induction) agent (eg, ketamine 4 mg/kg IM or midazolam 0.1 to 0.3 mg/kg IM [maximum dose 10 mg]). IM rocuronium (eg, 1 mg/kg for infants older than three months; 1.8 mg/kg for children one to six years of age) may be given to children with contraindications to succinylcholine. Onset of paralysis is slower by the IM route (up to six minutes for IM succinylcholine and up to nine minutes for IM rocuronium) [33]; the clinician must ensure full preoxygenation prior to administration, whenever possible, and provide continuous oxygen by nasal cannula at a rate of 1 L/kg per minute up to a maximum rate of 15 L/minute throughout the procedure. In addition, the clinician should be prepared to perform BMV if desaturation occurs before the patient is fully paralyzed for endotracheal intubation.

When giving RSI medication IM, the most concentrated available formulation of the agent should be used to try to keep the total volume administered less than 2 mL per injection.

Selection of sedation (induction) agent — Sedation for RSI should rapidly induce unconsciousness and have a short duration of action with minimal side effects. The rapid overview provides a list of medications with doses and indications (table 1).

For hemodynamically stable children without other complicating clinical features, we suggest etomidate for sedation during RSI. If available, propofol or thiopental is also an acceptable choice.

In children with specific clinical features, we suggest the following:

●Hypotension other than septic shock – Etomidate. Fentanyl is preferred by some experts for sedation of children with cardiogenic shock.

●Septic shock – Ketamine, unless otherwise contraindicated (eg, suspected open globe injury or catecholamine depletion [eg, hypotensive despite receiving vasopressor medications]).

Etomidate should not be used routinely in children with septic shock but may be appropriate if ketamine is otherwise contraindicated or unavailable. If etomidate is used, there is a potential for adrenal suppression. The emergency clinician should inform the physician assuming care in the intensive care unit that etomidate has been used and should avoid repeated bolus doses or etomidate infusion to maintain sedation after intubation. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Airway and breathing'.)

Although evidence is lacking, fentanyl is preferred by some experts for sedation of children with septic shock and suspected catecholamine depletion.

●Increased ICP – Etomidate or, in patients who are hemodynamically stable, propofol or, in countries where it is available, thiopental.

●Hypotensive with head injury – Etomidate.

●Status asthmaticus – Ketamine or etomidate.

●Status epilepticus – Choice depends upon hemodynamic status:

•Hemodynamically stable – Midazolam, propofol, or, if available, thiopental

•Hypotensive – Etomidate

More information on sedative (induction) agents used for RSI outside of the operating room in children is discussed separately. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Sedation (induction) agents'.)

Selection of paralytic agent — Paralytic agents provide complete muscle relaxation, which facilitates rapid tracheal intubation. They do not provide sedation, analgesia, or amnesia. Thus, a sedation (induction) agent must also be used both for RSI and when paralysis is maintained after intubation.

For paralysis of children undergoing RSI, we suggest using succinylcholine, if not contraindicated, or rocuronium with sugammadex immediately available for reversal. However, sugammadex has limited availability in most emergency departments. The physician must evaluate for a significant number of absolute and relative contraindications if he or she plans to use succinylcholine.

When succinylcholine cannot be used because of contraindications, we recommend rocuronium rather than vecuronium or pancuronium, regardless of the availability of sugammadex, because of its shorter duration of action and greater likelihood of achieving optimal intubating conditions. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Rocuronium' and "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Vecuronium and pancuronium'.)

The use of succinylcholine is absolutely contraindicated under the following circumstances (see "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Succinylcholine'):

●Chronic myopathy or denervating neuromuscular disease

●More than 48 to 72 hours after burns, multiple trauma, or an acute denervating event

●Extensive crush injury

●History of malignant hyperthermia

●Preexisting hyperkalemia

Relative contraindications to the use of succinylcholine include:

●Increased ICP – Although evidence supports elevated ICP with the use of succinylcholine in patients with brain tumors, most experts do not regard the potential for increased ICP as a contraindication to use succinylcholine in patients with traumatic brain injury. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Succinylcholine'.)

●Increased intraocular pressure.

●Known pseudocholinesterase deficiency (eg, organophosphate poisoning or congenital enzyme deficiency), which risks prolonged paralysis.

More information on paralytic agents used for RSI outside of the operating room in children is discussed separately. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Paralytic agents'.)

Protection — Protection during RSI refers to protecting the airway by preventing regurgitation of gastric contents and aspiration and maintenance of cervical spine precautions when neck trauma is suspected.

Every effort must be made to avoid BMV during RSI because of the increased risk of vomiting and aspiration that can occur with gastric distention following BMV. However, in patients who cannot be adequately preoxygenated, BMV with 100 percent oxygen with small tidal volumes and cricoid pressure is preferable to intubating a hypoxic patient. (See 'Preoxygenation' above.)

Cricoid pressure (Sellick maneuver) involves posterior pressure applied to the cricoid cartilage with the thumb and forefinger for the purpose of occluding the esophagus (figure 2 and figure 3). Cricoid pressure may help prevent gastric insufflation during BMV and is considered optional for this purpose. If cricoid pressure makes BMV more difficult due to occlusion of the airway, then it should be relaxed or removed.

In the past, cricoid pressure was considered essential for the protection of the airway from regurgitated stomach contents during RSI and is still used routinely by many anesthesiologists for RSI with induction of anesthesia. However, observational evidence in children intubated in the intensive care unit setting does not support the routine use of cricoid pressure during RSI. For example, in a retrospective cohort study of over 7800 critically ill children that adjusted for known risk factors for regurgitation, cricoid pressure during RSI was not associated with lower rates of regurgitation when compared with no cricoid pressure (1.9 versus 1.2 percent, respectively; adjusted odds ratio [aOR] 1.6; 95% CI 0.99-2.5). Risks with cricoid pressure include worsening the glottic view, occluding the airway, cervical spine movement in trauma patients, and esophageal injury in actively vomiting patients.

The use of cricoid pressure for RSI in adults and in the operating room is discussed separately. (See "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Positioning and protection' and "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Cricoid pressure during RSII'.)

Positioning for intubation — Proper positioning aligns the pharyngeal, tracheal, and oral axes (picture 1). (See "Technique of emergency endotracheal intubation in children", section on 'Positioning'.)

For children with suspected injury of the cervical spine, positioning must be accomplished without moving the neck. In-line manual stabilization must be maintained. (See "Technique of emergency endotracheal intubation in children", section on 'Cervical spine immobilization'.)

External laryngeal manipulation (bimanual laryngoscopy) — Ideally, with appropriate positioning and laryngoscopy, the vocal cords and glottis will be quickly identified.

If little or none of the glottic opening is visualized, ELM (also called bimanual laryngoscopy) may improve the view in some patients. ELM entails manipulating the larynx with the right hand in order to improve the view of the glottis (figure 3 and picture 2) (see "Technique of emergency endotracheal intubation in children", section on 'Laryngoscopy'):

●While holding the laryngoscope in the left hand, posterior displacement of the larynx is achieved with external pressure applied at the thyroid cartilage with the right hand.

●Once the optimal glottic view is obtained, the laryngoscopist has an assistant place their fingers in exactly the same spot on the thyroid cartilage, using the same direction and degree of force necessary to maintain the view.

Bimanual laryngoscopy may help the intubator identify the glottic anatomy or optimize the laryngeal view when visualization is suboptimal or inadequate despite appropriate laryngoscope blade positioning.

Alternatively, backward-upward-rightward pressure (BURP) is applied to the larynx by an assistant. However, this approach may not optimize the glottic view as effectively as bimanual laryngoscopy. (See "Direct laryngoscopy and endotracheal intubation in adults", section on 'Bimanual laryngoscopy (external laryngeal manipulation)'.)

Cricoid pressure — Gentle cricoid pressure, applied over the anterior neck at the cricoid cartilage, may improve the glottic view in young infants due to the anterior position of the glottis. When used, it should be applied after the sedative is administered and the patient becomes unconscious. If cricoid pressure worsens the view, it should be removed immediately and ELM attempted. Because ELM may better improve visualization of the glottis, we generally prefer to use this technique rather than cricoid pressure during laryngoscopy. (See 'External laryngeal manipulation (bimanual laryngoscopy)' above.)

Placement with confirmation — Onset of paralysis generally occurs within 30 to 60 seconds following the administration of succinylcholine or rocuronium. Once the child has become apneic, muscle relaxation can be confirmed by testing the jaw for flaccidity. Relaxation is adequate when the jaw can be easily opened.

After adequate muscle relaxation is confirmed, laryngoscopy can be performed with careful attention to proper technique. Oropharyngeal injury can be minimized while effectively exposing the glottis. After the tracheal tube has been placed and stylet removed, tube placement must be confirmed.

The technique of emergency endotracheal intubation in children is discussed in greater detail separately. (See "Technique of emergency endotracheal intubation in children".)

Postintubation management — Following placement and confirmation, the tracheal tube should be appropriately secured and a chest radiograph obtained to document proper placement and evaluate pulmonary status. (See "Technique of emergency endotracheal intubation in children", section on 'Post-intubation care'.)

Ongoing sedation and analgesia, generally with paralysis, should be maintained during the immediate postintubation period. Hemodynamic considerations generally dictate which pharmacologic agents should be used. A benzodiazepine is often used in combination with pancuronium or vecuronium. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis".)

For children who are hemodynamically stable, opioid analgesia (such as fentanyl or morphine) should be added.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Airway management in children".)

SUMMARY AND RECOMMENDATIONS

●Rapid overview – A rapid overview for performing rapid sequence intubation (RSI) is provided in the table (table 1). A checklist can ensure that all key aspects of preparation occur (figure 1). (See 'Approach' above.)

●Indications – For children who require emergency intubation, we recommend RSI (Grade 1B). Exceptions include patients who are in cardiac arrest or undergoing sedated intubation without paralysis because of an anticipated difficult airway. (See 'Indications' above.)

●Precautions – For patients with difficult airways (table 3 and table 4), an alternative intubation plan is required as described separately. (See "The difficult pediatric airway for emergency medicine".)

Clinicians should utilize techniques to minimize infectious risks and decrease the spread of airborne pathogens in children with suspected highly contagious and virulent pathogens who are undergoing RSI. (See 'Infection control precautions' above.)

●Approach – The steps of RSI include (table 2):

•Preparation – Perform a targeted history and physical examination, develop an intubation plan, and assemble necessary equipment and medications. (See 'Preparation' above.)

•Preoxygenation – Administer 100 percent inspired oxygen with technique dependent on the patient’s respiratory status and phase of RSI. (See 'Preoxygenation' above and 'Protection' above.)

•Pretreatment – Pretreatment with atropine is optional for selected patients as described above. (See 'Pretreatment' above.)

•Sedation/induction – Recommendations for sedation agents for RSI include (see 'Selection of sedation (induction) agent' above):

-Hemodynamically stable – For hemodynamically stable children without other complicating clinical features, we suggest etomidate rather than midazolam, propofol or, if available, thiopental. (Grade 2C).

-Increased intracranial pressure – For children with suspected increased intracranial pressure (ICP) who are hemodynamically stable, we suggest using etomidate or propofol rather than midazolam (Grade 2C). For children with suspected increased ICP who are hemodynamically unstable, we suggest etomidate rather than propofol (Grade 2C).

-Septic shock – For children with septic shock, we suggest ketamine rather than other sedation agents (Grade 2C). Whenever possible, hemodynamically unstable patients should receive rapid fluid infusion and, if needed, vasopressor agents prior to RSI.

For hemodynamically unstable children in septic shock with contraindications to ketamine, or if ketamine is unavailable, we suggest using etomidate or, if in a potentially catecholamine-depleted state, fentanyl (Grade 2C).

-Status asthmaticus – For children with status asthmaticus, we suggest ketamine rather than other sedation agents (Grade 2C).

-Status epilepticus – For hemodynamically stable children in status epilepticus, we suggest using midazolam, propofol, or, if available, thiopental (Grade 2C). For the hemodynamically unstable patient in status epilepticus, we suggest etomidate (Grade 2C).

•Paralysis – For paralysis, we suggest succinylcholine, if not contraindicated, or rocuronium with sugammadex immediately available for reversal (Grade 2B). When succinylcholine cannot be used because of contraindications, we recommend rocuronium rather than vecuronium or pancuronium (Grade 1B). (See 'Selection of paralytic agent' above.):

•Protection and positioning – Options for improving laryngoscopic view during RSI include:

-External laryngeal manipulation (ELM, evidence is limited for benefit in infants (figure 3 and picture 2)). (See 'External laryngeal manipulation (bimanual laryngoscopy)' above.)

-For young infants, gentle cricoid pressure (Sellick maneuver (figure 2) after sedation). If cricoid pressure worsens the view, remove it immediately and attempt ELM). (See 'Cricoid pressure' above.)

Every effort must be made to avoid BMV during RSI. However, if significant hypoxemia occurs, perform BMV; cricoid pressure during BMV may be used to prevent gastric distension. (See 'Protection' above.)

•Placement with confirmation – Confirm tracheal placement by primary methods (eg, auscultation of breath sounds over lung fields and not over the stomach, the appearance of mist inside the tracheal tube, and symmetric chest rise with positive pressure ventilation) and detection of end-tidal carbon dioxide (EtCO₂). (See "Technique of emergency endotracheal intubation in children", section on 'Confirming tube position' and "Carbon dioxide monitoring (capnography)".)

•Postintubation management – Secure the tracheal tube and obtain a chest radiograph. Ongoing sedation with benzodiazepines, analgesia (eg, fentanyl or, if hemodynamically stable, morphine), and paralysis are typically required immediately after RSI. (See 'Postintubation management' above.)