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Adventures in RSI

Pediatric airway management is a skill that integrates the three types of knowledge as described by the ancient Greeks: Episteme — theoretical knowledge, Techne — technical knowledge, Phronesis — practical wisdom — also called prudence. Here we’ll invoke each type of knowledge and understanding as we go beyond the anatomical issues in pediatric airway management – to the advanced decision-making aspect of RSI and the what-to-do-when the rubber-hits-the road.

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  Pediatric RSI Drugs

The following information is intended as a guideline for the acute management of children requiring rapid sequence intubation. Management of your patient may require a more individualized approach.

 Intubation/RSI

General PICU patient: Fentanyl/midazolam/rocuronium is a generally safe choice in most patients. Increased intracranial pressure: avoid ketamine and succinylcholine, use lidocaine for premedication Septic shock or hypotension: Consider ketamine, avoid etomidate (with the caveat that in primary cardiac failure, ketamine does have direct myocardial depressant effects and thus may not be the best choice for that population). Status epilepticus: Any is probably ok but may want to avoid ketamine.

 Neonatal Intubation and RSI

Don’t go half way. Using only a sedative is not better! Use both paralytic and sedative concurrently.

Articles of Interest

Do You Perform Rapid Sequence Intubation (RSI) in Emergencies?

Cricoid pressure is an integral part of the classic RSI without any robust evidence to support improved clinical outcome.

Rapid Sequence Induction and the Difficult Airway Module

Paediatric airway compromise requiring emergency management by rapid sequence induction (RSI) is a rare event in the Emergency Department. However, despite it being rare, it is associated with high mortality and morbidity with an overall death rate of 3.8%, the highest for a critically unwell child.

A Modern and Practical Review of RapidSequence Intubation in Pediatric Emergencies

Rapid-sequence intubation is derived from approaches developed by anesthesiologists to make emergency airway management as safe as possible for unfasted patients by attempting to limit the risk of vomiting and aspiration. We are not aware of randomized trials of RSI in a prehospital or ED setting, but decades of experience and numerous observational studies have demonstrated greater endotracheal intubation success with the addition of an NMB compared with a sedative alone.

Air Medical Pediatric Rapid Sequence Intubation

Overall pediatric RSI success rates were high despite less-than-optimal intubation conditions in the air medical environment. Rates for FAS and FASWD were lower for the youngest patients; this may represent an opportunity for education and training.

Atropine Not Needed for RSI

This is a complicated process, which is not made easier by adding additional medications, especially, when that added medication may lead to a dose calculation error, adverse side effect, or mask of more important causes of bradycardia. For these reasons, atropine is not be routinely needed as a part of RSI.

Breaking with tradition in paediatric RSI

Looks like more dogma has been lysed, and this study supports the current trajectory away from traditional teaching towards an approach more suitable for critically ill patients.

Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

Paediatric Rapid Sequence Intubation

ETT size = age/4 + 4, traditionally uncuffed until age 8, then cuffed (a ‘one-size smaller’ cuffed tube can be used in children <8 years), leak should occur at 20cmH2O if uncuffed.

Pediatric Rapid Sequence Intubation

Medications used in RSI can typically be divided into 2 categories: induction agents and neuromuscular blocking agents. The induction agents fall into many classifications, but all serve to sedate the patient to intubate. The most commonly used induction agents are the benzodiazepines (midazolam, lorazepam, and diazepam), thiopental, ketamine, etomidate, and the narcotics. Each has its advantages and disadvantages in specific clinical scenarios. All are given after the patient is preoxygenated but before any neuromuscular blockers are administered.

Pediatric rapid sequence intubation

Several key points...

Pediatric Rapid Sequence Intubation: lntraosseous Style

In summary, RST, once restricted to the operating room, has become a standard in emergency airway management tech - niques.In critically ill children, peripheral IV access may be difficult to obtain. This case and literature review illustrate that, in the event an emergency intubation is need ed and IV access to administer medications is not available, 10 access can be an acceptable route for RSI.

PEM Playbook – Adventures in RSI

Here we’ll invoke each type of knowledge and understanding as we go beyond the anatomical issues in pediatric airway management – to the advanced decision-making aspect of RSI and the what-to-do-when the rubber-hits-the road.

Rapid Sequence Intubation (RSI)

Etomidate 0.2-0.3 mg/kg IV, Rapid action, and short duration. It has no analgesic effect. It’s the most hemodynamically stable induction agent. This is an advantage over other agents in shock, anaphylaxis or any case where the further drop in blood pressure can be catastrophic.

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

Rapid-Sequence Intubation of the Pediatric Patient

RSI is superior to and more reliable than nasotracheal intubation, oral endotracheal intubation without neuromuscular blockade (NMB), and surgical cricothyroidotomy. Pharmacologic paralysis to facilitate ETI maximizes the probability of successful tube placement while minimizing untoward hemodynamic responses and complications. In several studies the safety of intubation and RSI performed in the ED by emergency physicians has been documented.

The Pediatric Airway and Rapid Sequence Intubation in Trauma

The goal of rapid sequence intubation is to emergently secure an airway safely. There are a variety of sedation options in pediatrics to achieve this goal. Nondepolarizing paralytic agents, such as rocuronium, are increasing in popularity in pediatric emergency medicine because of their shorter half-life and more favorable safety profile.

The Pediatric Airway and Rapid Sequence Intubation in Trauma

The authors illustrate how the airway anatomy in children differs from adults and how these differences can affect the procedure. They go on to discuss the equipment necessary for a successful RSI, including monitors, airway adjuncts, and capnography.

Use of Etomidate for Rapid Sequence Intubation (RSI) in Pediatric Trauma Patients...

Based on the results of the survey, the use of etomidate in pediatric trauma patients is common among urban, academic, teaching, level 1 pediatric trauma centers. A prospective evaluation of etomidate use for RSI in pediatric trauma patients to evaluate is potential effects on adrenal suppression and hemodynamics is warranted.