Rapid Intubation Sequence in Pediatrics

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1. Preparation
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Preparation is crucial and must be systematic. A failure at this stage compromises the entire procedure. Use mnemonics so you don't forget anything.

  • Ssuction: Appropriate suction catheter (Yankauer), connected and working.
  • Ooxygen: O2 source, mask with reservoir, nasal cannula, bag-mask device.
  • Airway (Airway): Laryngoscope (blade and handle, light working), endotracheal tubes (calculated size, one smaller, one larger), stylet, cuff syringe.
  • PPositioning and Pre-oxygenation: Optimize the patient's position (axis alignment), start pre-oxygenation.
  • MMonitoring and Medications: Complete monitoring (ECG, SpO2, NIBP, EtCO2), medications loaded and labeled.
  • Eteam and Emergency: Defined team roles, plan B and C (supraglottic devices, cricothyroidotomy).

Anticipating a difficult airway (VAD) is key. Look for indicators:

  • LEMON:
  • Look (Look): Facial characteristics (micrognathia, trauma, obesity).
  • Evalue (Assess 3-3-2): Interincisor distance (>3 fingers), hyomental distance (>3 fingers), thyrohyoid distance (>2 fingers).
  • Mallampati: Visualization of pharyngeal structures.
  • Obstruction: Presence of stridor, dysphonia, epiglottitis.
  • Neck Mobility: Limited neck mobility (cervical collar, arthritis).
2. Preoxygenation
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The objective is to "denitrogenize" the pulmonary functional residual capacity, creating an oxygen reservoir that delays desaturation during apnea.

  • Administer 100% O2 (FiO2 1.0) for 3-5 minutes.
  • Use a mask with a well-sealed reservoir at high flows (10-15 L/min).
  • In cooperative patients, ask them to breathe normally.
  • In uncooperative patients or patients with altered consciousness, it may be necessary to assist ventilation with a bag-mask, but be careful not to inflate the stomach.
  • Apneic Oxygenation: Consider using a high-flow nasal cannula (1-2 L/kg/min) throughout the procedure (from preoxygenation to after intubation) to prolong safe apnea time.
3. Pretreatment
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Administer specific drugs 3 minutes before induction to mitigate adverse physiologic responses to laryngoscopy and intubation. Its use is selective and not routine.

  • LIdocaine: 1.5 mg/kg. Consider in patients with airway reactivity (asthma) or suspected intracranial hypertension (ICH).
  • Opyoid (Fentanyl): 1-3 mcg/kg. Helps attenuate the sympathetic response (tachycardia, HBP) ​​to laryngoscopy. Useful in ICH and heart disease.
  • Atropine: 0.02 mg/kg (min 0.1 mg). Consider in children < 1 year (prone to vagal bradycardia) or if succinylcholine is used.
  • Defasciculant: Small dose (10%) of a non-depolarizing relaxant (e.g. Rocuronium 0.1 mg/kg) 3 min before Succinylcholine to prevent fasciculations. Its use is controversial.
4. Paralysis with Induction
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It is the heart of the SIR. An induction agent (sedative/hypnotic) is administered immediately followed by a neuromuscular blocking agent to rapidly achieve unconsciousness and muscle relaxation.

  • Ketamine: 1-2 mg/kg IV. Ideal for hypotension or bronchospasm due to its sympathomimetic and bronchodilator properties. Produces dissociative sedation.
  • Etomidate: 0.2-0.3 mg/kg IV. Hemodynamically stable (cardioneutr), ideal in trauma or shock. Causes transient adrenal suppression.
  • Propofol: 1-3 mg/kg IV. Quick start and short duration. Causes significant hypotension and respiratory depression. Avoid in unstable patients.
  • Midazolam: 0.1-0.3 mg/kg IV. Slower start and longer duration. Not ideal for SIR, but can be used if others are not available.
  • Succinylcholine: 1-2 mg/kg IV. Depolarizing. Faster onset (45-60s) and shorter duration (5-10 min). Contraindicated in hyperkalemia, neuromuscular disease, burns >24 hours, crushing, prolonged immobilization.
  • Rocuronium: 1.2 mg/kg IV. Not depolarizing. Quick start (60-90s) and longer duration (30-60 min). It is the safest alternative to succinylcholine. It has an antidote (Sugammadex).
5. Positioning
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Once the patient is unconscious and relaxed, optimizing the position of the head and neck is essential to align the oral, pharyngeal and laryngeal axes, facilitating visualization of the glottis.

  • Children > 2 years: Place a bun or pillow under the head to elevate it, followed by atlanto-occipital extension.
  • Infants and children < 2 years: The prominent occiput naturally aligns the axes. They generally only need a small bun under the shoulders to prevent neck flexion.
  • The goal is for the external auditory canal to be at the level of the sternal fork.
6. Tube Passage
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The timing of laryngoscopy. It should be a quick (<30 seconds), gentle and deliberate procedure.

  • Hold the laryngoscope with your left hand.
  • Insert the blade through the right corner of the mouth, moving the tongue to the left.
  • Advance the sheet: if it is curved (Macintosh), until the vallecula; if it is straight (Miller), exceeding the epiglottis.
  • Pull up and forward (at a 45° angle) to expose the vocal cords. Do not pry on the teeth!
  • Visualize the vocal cords (Cormack-Lehane Grade).
  • Insert the endotracheal tube (ETT) through the cords until the cuff extends 1-2 cm beyond them.
  • Remove the stylet (if used).
  • Inflate the cuff with the minimum pressure necessary to seal.
  • Connect to O2 source and capnograph.
7. Post-Intubation
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Intubation does not end with the passage of the tube. Confirmation, fixation and subsequent management are vital for patient safety.

  • Primary Confirmation (Clinical): Direct visualization of the tube passing through the chords, auscultation of bilateral vesicular murmur in the apex and axillae, absence of sounds in the epigastrium, steam in the tube, symmetrical chest expansion.
  • Secondary Confirmation (Gold Standard): Quantitative continuous wave capnography. Detection of expired CO2 in 3-5 breaths confirms tracheal position.
  • Tertiary Confirmation: Chest x-ray to verify depth (tip 1-2 cm from the carina).
  • Fix the tube securely.
  • Initiate analgesia and sedation for patient comfort and to avoid self-extubation.
  • Adjust mechanical fan parameters.
  • Place orogastric tube for gastric decompression.
Final Evaluation
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1. What is the "Gold Standard" method to confirm correct endotracheal tube placement?

2. In what age group is pretreatment with Atropine recommended to prevent bradycardia during SIR?

3. A 6-year-old child with asthma and hypotension needs an SIR. What would be the most appropriate induction agent?

4. What is an absolute contraindication for the use of Succinylcholine?

5. The main objective of preoxygenation is:

Literature
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  • Kerrey, B. T., Rinderknecht, A. S., & Geis, G. L. (2012). Rapid sequence intubation for pediatric emergency physicians. Annals of Emergency Medicine, 60(6), 767-778.
  • Roberts, J. R., & Hedges, J. R. (2019). Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care (7th ed.). Elsevier.
  • Doniger, S. J., Sharieff, G. Q. (2007). Pediatric rapid sequence intubation. Journal of Emergency Medicine, 33(3), 289-296.
  • American Heart Association. (2020). Pediatric Advanced Life Support (PALS) Provider Manual.