Pediatric Rapid Sequence Intubation: An In-depth Review
- Preoxygenation allows oxygen to replace nitrogen in
the lungs, permitting longer periods of apnea before hypoxemia occurs.
- Intubation has the potential to exacerbate an undiagnosed, underlying spinal cord injury. Attention should focus on maintaining cervical spine immobilization
- Manual manipulation of the neck for the purpose of positioning prior to intubation (e.g., the "sniffing" position or hyperextension of the neck and "jaw thrust" and "chin lift" maneuvers) can be associated with increased risk for secondary cervical spine injury and should be avoided in pediatric trauma patients.
- The recent PALS updates recommend the use of cuffed endotracheal tubes, except in the newborn period.
Pediatric advanced airway management is a critical intervention performed for ill or injured children in the emergency department (ED). Approximately 270,000 children require endotracheal intubation in the emergency department each year, comprising 0.2% of all ED visits.1 Despite its infrequent occurrence, endotracheal intubation is a potentially lifesaving procedure for children with respiratory compromise and impending respiratory failure. Factors related to pediatric airway anatomy, provider education and training, and the availability of the appropriate equipment can significantly affect patient outcomes.
Safe emergent endotracheal intubation can be achieved through the process of rapid sequence intubation (RSI), using a sequential approach to preparation, sedation, and paralysis prior to intubation.2 RSI must be differentiated from rapid sequence induction used by anesthesiologists to induce general anesthesia. RSI is the preferred method of intubation in the ED where most patients present with varying levels of consciousness and protective airway reflexes, and increased potential for pulmonary aspiration of gastric contents.2,3,4 While there are no absolute contraindications to RSI, patients in cardiac arrest and those who are comatose without a gag reflex generally do not warrant RSI medications prior to intubation.2 Decisions involving the RSI process are impacted not only by the individual case at hand, but also by a provider’s stylistic approach. As with most things in medicine, practice variation exists and the choices of medications will differ depending on the clinical scenario. This chapter serves as a review of standard practice in the ED when caring for the pediatric trauma patient who requires intubation.
Decision to Intubate
The pediatric trauma patient who is awake, talking or crying, and able to maintain his or her own airway can be managed conservatively with supportive care (e.g., FiO2 by facemask or nasal cannula). See Table 1 for recommendations for emergency endotracheal intubation in trauma patients.
When deciding on the safest and most appropriate technique, factors including the risk for secondary cord injury, pediatric specific anatomy, presence of traumatic injury, and the provider’s expertise should be considered.6
It is necessary for ED clinicians to obtain a quick history prior to deciding which medications are appropriate for pediatric RSI. A simple mnemonic, AMPLE serves as a reminder for the hurried clinician: A = allergies & airway history, M = medications, P = past medical history, family history, and anesthetic history, L = last oral intake, and E = events leading up to the intubation7,8 (See Table 2). Before preparing for intubation, a rapid but thorough assessment of the patient’s head, neck, neurologic status, airway, and breathing should be performed.9
Airway management in the trauma patient is complicated by the potential for cervical spine injury. A large multicenter study involving 17 hospitals across the United States was conducted in children < 16 years of age to identify risk factors for cervical spine injury.10 The study identified eight factors associated with cervical spine injury in children after blunt trauma: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. The authors concluded that having one or more risk factors was 98% sensitive and 26% specific for detecting cervical spine injury.
Cervical spine injury may be occult and present without radiographic abnormalities. SCIWORA syndrome (spinal cord injury without radiologic abnormality) refers to spinal injuries in the absence of identifiable bony or ligamentous injury on plain radiographs or computed tomography (CT), though often abnormalities may be detected on magnetic resonance imaging (MRI). SCIWORA occurs most often in the pediatric population and accounts for up to two-thirds of severe cervical spine injures in children younger than 8 years of age.11 The elasticity and increased mobility of the pediatric spine increase the risk of cord injury from flexion, extension, and transverse forces. Children with spinal cord injuries will often present with immediate or transient loss of motor function in their arms and/or legs and variable sensory loss. It is important for the ED clinician to obtain a detailed injury history, including chief complaints and physical findings reported from the scene, when considering the risk of spinal cord injury. Procedures such as intubation have the potential to exacerbate an undiagnosed, underlying cord injury. Particular attention should focus on maintaining cervical spine immobilization and minimizing the risk of secondary injury during intubation of a pediatric trauma patient.
Providers intubating non-trauma pediatric patients are instructed to position the patient with the neck in mild extension, known as the "sniffing" position, to better align the oral and pharyngeal axes and allow maximal laryngeal visualization.9 Ideally, the patient should be positioned with the external auditory meatus on the same plane as the sternal notch. Because young children have a prominent occiput, a towel roll placed underneath the shoulders will assist with achieving the desired position. The larger tongue-to-oropharynx ratio in children also may require a "jaw thrust" or "chin lift" maneuver to adequately open the airway. Hyperextension of the neck may occlude the child’s airway and should be avoided.
Positioning the pediatric trauma patient is more challenging and efforts should focus on maintaining in-line cervical spine immobilization at all times. The "sniffing" position is preferred in non-trauma patients, but it extends the occiput at the atlas and should be avoided in patients with known or suspected C1/C2 injuries.12-14 The "jaw thrust" and "chin lift" maneuvers have also been shown to cause spine distraction in cases of lower cervical spine instability not mitigated by rigid collar use.12-14 During intubation, the anterior portion of the cervical collar can be opened to allow for adequate jaw mobilization and laryngeal visualization. A second provider should use two hands to ensure cervical spine stability during the entire intubation process. Finally, the patient should be positioned as close to the head of the bed as possible and the bed should be elevated to above the waist level of the person intubating to facilitate correct visualization.
Preoxygenation is an essential preparation phase prior to pediatric RSI to achieve maximal pre-intubation oxygen saturation. Many children who require intubation are hypoxic or have impeding respiratory failure and very poor oxygen reserves. Children also have a higher oxygen consumption rate with a lower functional residual capacity and alveolar volume compared to adults, making them more susceptible to precipitous decline in oxygen saturation, particularly during intubation.2,15
The goals of preoxygenation are to achieve 100% oxygen saturation prior to intubating, to maximize oxygen stores in the lungs and bloodstream, as well as to denitrogenate the residual capacity of the lungs. The replacement of nitrogen in the lungs permits longer periods of apnea without consequential hypoxemia. Two minutes of administering 100% oxygen to a spontaneously breathing child will wash out approximately 95% of alveolar nitrogen.2,9 Application of 100% oxygen at 15 L/minute via a nonrebreather mask for at least 3 minutes maximizes the oxygen reservoir in the alveoli and the rest of the body.16 In the adult literature, high flow nasal cannula (HFNC) at 5-15 L/minute and basic nasal cannula at < 5 L/minute have also been used to facilitate preoxygenation during the apneic period prior to intubation. Some studies report success with HFNC preventing significant desaturations below 90% by offering a safety buffer during periods of apnea and hypoventilation.16,17 Additional research is needed to adequately evaluate the efficacy of this intervention in critically ill pediatric patients.
Noninvasive positive pressure ventilation (e.g., bag-mask ventilation) is reserved for patients who cannot achieve acceptable oxygen saturation due to inadequate ventilation or advanced lower airspace disease.2,8,16,18 Caution should be taken when administering positive pressure ventilation (PPV) via manual bag-mask ventilation as a means of preoxygenation because of gastric insufflation and the risk of emesis and aspiration. When bag-mask ventilation is necessary, steps should be taken to ensure adequate ventilation. First, clear the child’s airway of blood, secretions, or debris. Significant mouth and facial trauma can inhibit a good mask-to-face seal and negatively affect adequate chest rise. Choose an appropriately sized mask that fits over the nose and extends down to the anterior bony aspect of the chin, completely encircling the mouth and nose. Oropharyngeal airways (OPA) can be used in a child without a gag/swallow reflex to help maintain a patent airway by positioning the tongue anteriorly and relieving posterior pharyngeal obstruction. The correct size OPA is measured from the middle of the patient’s mouth to the angle of the jaw. An OPA that is too small can force the tongue back into the pharynx, causing airway obstruction and occlusion of the glottic opening. One that is too large may cause pharyngeal trauma and blood in the airway. The most accepted method for insertion in a trauma patient involves using a tongue depressor or manually holding the tongue forward while inserting the OPA right side up. The child- (500 mL) or adult- (1600 mL) sized self-inflating bags with an oxygen reservoir can be used to deliver adequate tidal volumes and close to 100% FiO2 to all patients including infants. Most self-inflating bag systems are fitted with a pressure relief valve (also called a "pop-up valve") for the purpose of preventing accidental over-pressurization of the lungs. The typical pressure cutoff is 30-35 cm H2O pressure, but a bypass clip can be used in cases where there is a need for higher pressures to maintain adequate ventilation.
Cricoid Pressure and External Laryngeal Manipulation
The use of cricoid pressure, often referred to as the Sellick maneuver, during intubation is controversial. Currently, there is insufficient evidence to recommend the use of routine cricoid pressure to prevent aspiration during endotracheal intubation in children.2,7,9 Using the thumb and index or middle finger, pressure is applied posteriorly over the cricoid cartilage to compress the esophagus once the patient is unconscious. Manipulation of the trachea on the esophagus by this maneuver should be used with caution. When performed incorrectly, cricoid pressure may interfere with direct visualization of the larynx and in rare, severe cases, may result in esophageal rupture if applied in patients with active vomiting.7
External laryngeal manipulation (ELM) is another airway maneuver employed to facilitate laryngeal view during direct laryngoscopy.19 A technique called the "BURP" maneuver is one method of ELM used to better visualize the glottis during difficult intubations. This acronym guides the intubator to move the larynx posteriorly toward the cervical vertebrae (backwards), superiorly (upwards), and laterally to the right (rightward pressure) during laryngoscopy.20,21 Pediatric and trauma-specific studies using ELM are lacking. One pediatric simulation study showed no difference in success rate using this technique.21 Cricoid pressure and ELM should be used with caution after a thorough evaluation of the risks and benefits to the pediatric trauma patient.
When preparing for successful RSI, all necessary monitors, equipment, personnel, and medications should be assembled. A helpful mnemonic to aid with preparation is SOAPME: [S]uction with a Yankauer tip, [O]xygen, [A]irway equipment (uncuffed endotracheal tube [ETT] size = 4 + [age/4], use 0.5 smaller for a cuffed ETT, See Table 3,
[P]harmacologic agents and
[M]onitoring [E]quipment, including pulse oximetry and ETCO2 monitoring.2 Guidelines for sizing laryngoscope blade and ETTs are based on the patient’s age (See Table 4).
Table 3. Equipment Preparation
S: Suction with a Yankauer tip
A: Airway equipment
P: Pharmacologic agents
ME: Monitoring Equipment
Conventional teaching instructs clinicians to use uncuffed ETTs in children < 8 years of age; however, current research confirms the safe use of cuffed tubes in all infants and pediatric patients except in the newborn period.22-24 In younger children and infants, the subglottic area is the narrowest part of the pediatric airway and creates an anatomical seal around the ETT at that level. Care should be taken to not place an uncuffed ETT that is too large, as it can cause mucosal injury from excessive pressure. Caution with using cuffed tubes in young children has focused on the potential for causing increased airway resistance, laryngeal mucosal injury, and subsequent development of subglottic stenosis. Current cuffed ETTs are equipped with low-pressure, high-volume cuffs that provide a safer tracheal seal by using lower inflation pressures, allow pressure adjustments in the seal to be made over time, and decrease the potential risk of gastric aspiration. Cuffed ETTs also facilitate more accurate control of positive pressure ventilation because of smaller air leaks. A prospective cohort study of 597 children younger than 5 years of age demonstrated no significant difference between cuffed and uncuffed ETT in the incidence of post-extubation subglottic edema.22 Similarly, a randomized control trial of 2246 children younger than 5 years of age showed that cuffed ETTs did not increase the risk of post-extubation stridor.23 Regardless of whether an uncuffed or cuffed ETT is used, it is important that clinicians use the correct sized ETT to avoid complications such as airway trauma and mucosal ulceration.24
Premedications — Adjuncts
Atropine. Infants and children can experience bradycardia during intubation secondary to hypoxia, vagal nerve stimulation, and effects of medications such as succinylcholine.25,26 Atropine is a nonspecific antagonist of acetylcholine at the muscarinic receptor and prevents reflex bradycardia by inhibiting vagal stimulation of the sinoatrial node. In one retrospective cohort study, approximately 10% of emergency intubations were associated with bradycardia (indicated by a pulse of < 80 beats per minute for children younger than 2 years and < 60 beats per minute for children older than 2 years).27 The efficacy of atropine in preventing bradycardia associated with intubation has been questioned in recent studies.27,28 The use of atropine, however, as adjunctive therapy is encouraged for the following situations: 1) all patients < 1 year of age, 2) children < 5 years of age receiving succinylcholine, 3) adolescents receiving a second dose of succinylcholine, and 4) patients who are experiencing bradycardia prior to intubation.25-29
Potential adverse effects include sinus tachycardia, mydriasis, xerostomia, decreased micturition, and hyperthermia.26 It is advised to do a pupillary exam, especially for the pediatric trauma patient, before giving atropine because mydriasis can persist for hours after a single dose of atropine.
When administered, atropine should be given 1-2 minutes prior to any sedative or paralytic agent. The recommended dose is 0.02 mg/kg (minimum 0.1 mg, maximum 0.5 mg child, 1 mg adolescent).2 Doses < 0.1 mg have been associated with paradoxical bradycardia. Weight-based dosing in low-birth weight and premature newborns may be less than the recommended minimum dose of 0.1 mg per dose. Consultation with a neonatologist is recommended when using atropine in this population.
Lidocaine. Lidocaine is used as an adjunct to pediatric RSI for the purpose of attenuating the increase in intracranial pressure (ICP) associated with laryngoscopy and intubation. Its mechanism of action is thought to include cough reflex suppression, brain stem depression, and decreased cerebral metabolism.4 Providers should be aware of lidocaine’s potential for exacerbating hypotension and must be prepared to treat this complication early and appropriately, especially in trauma patients. Pediatric studies regarding the efficacy of the use of lidocaine are conflicting and its addition to the RSI algorithm should be examined on a case-by-case basis.4,7,9,18,30,31
The recommended lidocaine dose for pediatric RSI is 1.5 mg/kg IV administered 2-3 minutes prior to intubation.2
Sedatives and Analgesics
Several factors should be considered when selecting the appropriate sedative and analgesic agents to use for ED-initiated RSI. Practice variation in choices of sedative agents is to be expected. Hospital settings differ in medication availability and provider comfort and experience using the different agents. Minimal adverse side effects are tolerable as long as the medications are easy to administer, rapid in onset, and have a high therapeutic index with few drug interactions.
Etomidate. Etomidate has become a popular sedative in pediatric intubations in the ED because of its rapid onset of action (5-15 seconds), short duration of sedation (5-14 minutes), and minimal cardiovascular side effects.31-35 The use of etomidate is favored for children with unstable cardiovascular status because of its minimal effects on mean arterial pressure. It is also commonly used in trauma patients who have sustained head or ocular injury because it induces a transient decrease in intracranial and intraocular pressures.
Several recent studies have evaluated the efficacy and safety of etomidate in pediatric RSI. One prospective observational study of 77 pediatric patients demonstrated successful first attempt intubations in 65.8% of patients using an etomidate dose of 0.3mg/kg IV.34 Another study of 105 pediatric patients younger than 10 years reported minimal cardiovascular side effects with etomidate at 0.3 mg/kg dosing without the adverse effects of adrenal suppression, myoclonus, status epilepticus, or new-onset seizures.33 More recent studies have questioned the safety profile of even a single dose of etomidate for RSI. A major consideration in the use of etomidate is the dose-dependent, reversible inhibition of adrenocortical activity leading to decreased cortisol production for up to 15 hours.7,32 Etomidate blocks the enzyme 11-ß-hydroxylase, which is involved in adrenal steroid production. One randomized controlled study of etomidate use in adult trauma patients36 and one systematic review of elective surgical patients37 confirmed a significant difference in cortisol levels after etomidate administration. Data on patient specific outcomes remains conflicting. The above referenced systematic review of elective surgical patients37 and another observational study involving adults with sepsis38 showed no statistically significant increase in mortality or hospital length of stay associated with etomidate use. On the contrary, one adult trauma study36 and another study involving non-cardiac surgical patients39 reported significant increases in cardiovascular morbidity, number of ventilator days, lengths of ICU and hospital stay, and risk for 30-day mortality associated with etomidate use.
Additional potential adverse effects include myoclonic activity, such as coughing or hiccupping, and decreased seizure threshold in patients with known seizure disorders.28
The recommended RSI dose range for etomidate is 0.2 to 0.4 mg/kg IV with clinical recovery in 10 to 15 minutes.29,40
Ketamine. Ketamine is a dissociative sedative-analgesic derived from phencyclidine (PCP). Patients given ketamine characteristically exhibit a trance-like state with open eyes, a slow nystagmic gaze, and occasional mild respiratory depression despite preserved airway reflexes.7 It is the favored agent for patients with respiratory failure secondary to severe bronchospasm and asthma because of its bronchodilatory effects on respiratory smooth muscles. An additional side effect of ketamine is the sympathomimetic stimulation of the cardiovascular system leading to transient increases in heart rate, blood pressure, and cardiac output.
While ketamine may help the cardiovascular status of patients with signs of shock, it is often avoided in patients with increased ICP, eye injuries, and uncontrolled hypertension because of the concern for exacerbating these conditions. The original recommendations for caution in these patients was based on early data from patients with non-traumatic intracranial lesions leading to cerebral spinal fluid (CSF) outflow obstruction and resultant increased ICP.41 More recent evidence shows ICP to remain normal (i.e., < 10 mmHg), with associated increases in mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) after ketamine use in healthy patients.20,41,42,43 Additional research suggests that in acute head trauma, the compensatory mechanisms of CSF flow and venous circulation remain intact, and therefore increases in cerebral blood volume (CBV) associated with ketamine do not lead to increased ICP.41,42 Further research comparing ketamine to alternate RSI induction agents is necessary to substantiate its use in patients with head trauma.
Additional relative contraindications to ketamine use include thyrotoxicosis and major depressive disorders because of an emergence phenomenon that can be associated with visual and auditory hallucinations.7
The recommended RSI dose for ketamine is 1.5-2 mg/kg IV with clinical recovery within 10-15 minutes.2
Propofol. Propofol is a lipophilic sedative-hypnotic that produces general anesthesia.2 It has a very rapid onset (10 to 20 seconds) and short duration of action (10 to 15 minutes).40,44 Propofol use is associated with vasodilation, decreases in MAP and ICP, and myocardial depression. Its use in RSI should be reserved for hemodynamically stable patients without evidence of hypotension.
Propofol use can be beneficial when intubating patients with refractory status epilepticus.45,46 When given as a bolus dose, propofol suppresses seizure activity by acting as a gamma-aminobutyric acid (GABA) A-agonist.45 At high doses, propofol functions as a general anesthetic agent, and physicians must be prepared to intubate patients with status epilepticus to protect their airway.
Propofol contains egg lecithin and soybean oil and therefore is unsafe to use in patients with allergies to eggs and/or soybeans. When given in high doses for a prolonged period of time, propofol may be associated with a condition known as propofol infusion syndrome (PIS).47,48 This syndrome is characterized by severe lactic acidosis, rhabdomyolysis, acute renal failure, hyperlipidemia, recalcitrant myocardial failure, hypotension, bradycardia, and death.47,48 Proposed risk factors for developing PIS include head injury, airway infection, young age (< 18 years of age), low carbohydrate intake/high fat intake, inborn errors of fatty acid oxidation, high doses of propofol for more than 48 hours, and combined use of catecholamine vasopressors and/or glucocorticoids.47,48 Serum lactate and creatine phosphokinase levels should be monitored closely during propofol infusions.
The recommended RSI dose range for propofol is 1.5-3 mg/kg IV with clinical recovery in 10 minutes.2 Higher doses, such as 3-5 mg/kg IV followed by 1-15 mg/kg/hr continuous infusion, may be required for cessation of refractory seizure activity.
Midazolam. Midazolam is a rapid-acting benzodiazepine with amnestic, anxiolytic, and anticonvulsant properties. Midazolam is the sedative agent of choice for hemodynamically stable patients presenting with status epilepticus because of its potent anticonvulsant effects.2,30,40 Side effects of midazolam include respiratory depression with associated apnea, myocardial depression, and hypotension secondary to a dose-related decrease in systemic vascular resistance (SVR). Because of the potential for significant cardiovascular side effects, it should be avoided in hemodynamically unstable patients.
The recommended RSI dose for midazolam is 0.1-0.2 mg/kg IV with clinical recovery in 30-60 minutes.2
Thiopental. Thiopental is a short-acting barbiturate sedative with a short onset of action (10-20 seconds) and duration of action (5-10 minutes). Thiopental does not have analgesic effects, so it should be used in conjunction with an analgesic. Associated side effects of thiopental include decreases in ICP and cerebral oxygen consumption, which make its use favorable in patients with head trauma or intracranial infections. Significant adverse effects include profound hypotension, myocardial depression, and bronchospasm from histamine release. Thiopental should be avoided in patients with cardiovascular instability and in those with asthma.
The recommended RSI dose for thiopental is 2-5 mg/kg IV.2
Narcotics. Narcotics, such as fentanyl and morphine, may be used as sedative agents for RSI. They provide both anesthesia and analgesia while decreasing sympathetic tone and therefore are good agents for patients exhibiting pain prior to intubation. Compared with morphine, fentanyl is more lipophilic, causing a faster onset (1-2 minutes) and shorter duration (approximately 30 minutes) of action. Fentanyl also causes less histamine release but can be associated with chest wall rigidity and ventilation difficulties when rapidly infused. Morphine has a longer onset of action (3-5 minutes) and longer duration of action (4-6 hours). Histamine release associated with morphine may cause significant pruritus. The large doses of both medications often required to achieve significant sedation and analgesia can lead to prolonged sedation, a decrease in SVR, and hypotension.2,40
The recommended RSI dose for fentanyl is 2-4 mcg/kg IV and morphine is 0.1-0.2 mg/kg IV.29
See Table 5 for a summary of RSI medications.
Neuromuscular Blocking (Paralytic) Agents
Neuromuscular blocking agents provide muscle paralysis to facilitate endotracheal intubation. They should be used in conjunction with a preceding sedative to achieve full RSI effect.
There are two main classes of neuromuscular blocking agents: depolarizing and non-depolarizing. Both induce motor paralysis by inhibiting acetylcholine stimulation of nicotinic receptors at the neuromuscular junction.
Succinylcholine. Succinylcholine is a commonly used paralytic agent in pediatric RSI. Its benefits include an extremely fast onset (< 1 minute) and a short duration of action (4-6 minutes).2,7,49 It is most often used in previously healthy children and in cases where brief, transient paralysis is preferred such as known or suspected difficult intubations.
There are potential significant adverse effects associated with succinylcholine use. Administration of this drug may cause bradycardia and, in extreme cases, asystole with repeat doses. For these reasons, atropine is typically recommended as an adjunct in pre-medicating children < 5 years of age or adolescents receiving a second dose of succinylcholine. Succinylcholine is absolutely contraindicated in children with underlying muscular dystrophy because it interacts with the unstable muscle membranes leading to severe, prolonged rhabdomyolysis and life-threatening hyperkalemia. Succinylcholine can also cause significant hyperkalemia and should be avoided in the setting of malignant hyperthermia, large body surface area burns, multisystem trauma, and traumatic spinal cord and other denervating injuries. Caution with succinylcholine use in multisystem injured patients stems from the proposed upregulation of skeletal muscle acetylcholine receptors that occurs approximately 2-3 days after injury.2,50 In this situation, when depolarized, there is an even larger efflux of potassium leading to extremely elevated serum potassium levels and myocardial dysfunction.2,50 Succinylcholine may also lead to an increase in ICP and intraocular pressure and should be used with caution in patients with intracranial injuries, brain tumors, and penetrating eye trauma.2,44
It is important to note that defasciculation and priming are no longer recommended when using succinylcholine due to increased medication errors associated with this practice.2
The recommended dose for RSI is 2 mg/kg IV in infants and younger children. In older children, the dose is 1 mg/kg IV, similar to adults. The age-related dosing difference stems from the fact that succinylcholine is distributed in the extracellular fluid, and younger children tend to have increased extracellular water compared to older children.2
Rocuronium. Rocuronium is a non-depolarizing neuromuscular blocking agent that induces muscle paralysis by competing with the nicotinic cholinergic receptor. It has a rapid onset of action (< 1 minute) and can last up to 45 minutes. It is recommended in patients with absolute contraindications to succinylcholine such as muscular dystrophy and/or malignant hyperthermia.
Rare adverse effects include tachycardia and hypertension.32
The recommended dose for pediatric RSI is 1 mg/kg IV.2
Vecuronium. Vecuronium is an alternative nondepolarizing agent that has a longer onset of action (90-120 seconds) and duration of action (20-60 minutes). Caution should be taken when using this agent in cases where endotracheal intubation may be difficult and prolonged paralysis contraindicated.
Rare adverse effects include hypersensitivity reactions, including anaphylaxis.2
The recommended dose for pediatric RSI is 0.15-0.3 mg/kg IV.2
Pancuronium. Pancuronium is a longer-acting nondepolarizing agent with a much slower onset (2-5 minutes) and long duration of action (120-150 minutes). It is primarily used for maintenance of paralysis after initial RSI. Significant side effects include a profound vagolytic effect leading to increased heart rate, blood pressure, and cardiac output.2
The recommended dose is 0.1 mg/kg IV for infants and 0.15 mg/kg IV for children.2
Confirmation of Endotracheal Intubation
Upon successful endotracheal intubation, the ETT should be secured and proper positioning confirmed. Appropriate ETT depth (cm from the upper lip) can be calculated by using the equation: ETT depth (cm) at the lips = 3 × ETT size (mm). Breath sounds should be auscultated at bilateral axillary areas and adequate, symmetric chest rise confirmed during bag insufflation. End-tidal CO2 monitoring should be used post-intubation and measurable CO2 return confirmed. This can be achieved as a one-time immediate confirmation using a colorimetric device or continuously with mainstream monitoring directly from the ETT, the preferred method. Lastly, a chest radiograph should be obtained to confirm proper ETT position. Documentation of vital signs, including temperature, heart rate, blood pressure, pulse oximetry, and end-tidal CO2 level and airway reassessments are recommended every 5 minutes.
Complications of Endotracheal Intubation
Complications of pediatric intubations occur more frequently than in their adult counterparts7 (See Table 6). The frequency of complications associated with endotracheal intubation in pediatric patients outside the operating room has been estimated to range between 15-38%.28 A retrospective observational study using video review of pediatric intubations suggested that complications associated with pediatric RSI may be more prevalent than previously reported.51 Sixty-one percent of their intubations (70/114) were associated with at least one adverse event. The most common complications were oxygen desaturation, right mainstem intubation, and esophageal intubation. Two intubations were associated with physiologic deterioration requiring cardiopulmonary resuscitation.
Anatomic characteristics of the pediatric head, neck and airway may pose challenges to the ED clinician caring for the pediatric patient and contribute to potential complications.9,15,27 Children have proportionally larger heads and occipital prominences, causing passive anterior neck flexion and airway obstruction when lying supine. Their larger tongue to oropharynx ratio offers less visualization during intubation. The epiglottis in children is long, floppy, narrow, and more anteriorly located in the larynx, making visualization of the cords more difficult. The trachea in children is also shorter, narrower, and more anteriorly positioned, increasing the risk of right mainstem intubation. Complications during endotracheal intubation can be quite frightening even to the experienced clinician. Patient-related complications include oxygen desaturation, emesis, aspiration, laryngospasm, and trismus. Technical and intubator-related problems involve cuff leaks, equipment failure, medication dosage errors, dental and lip trauma, vocal cord avulsion, esophageal intubation, mainstem intubation, and tube dislodgement. Patients may develop dysrhythmias, hypotension, pneumothorax, bleeding and even cardiac arrest during endotracheal intubation. ED providers should anticipate potential complications and be prepared to manage them.3,52,53
Video laryngoscopy is becoming a popular tool to aid clinicians with RSI in both pre-hospital and hospital settings. Most video laryngoscopy units allow for both direct and indirect (projected on a video monitor) visualization of the glottis during intubation. Monitor viewing allows for shared situational awareness and enhances bedside teaching when the intubator is a trainee. Blade sizes and choices are similar to conventional laryngoscopy blades; however, there are some (e.g., angulated blade, anatomically shaped blade with guide channel) that are specific to videolaryngoscopy with which the intubator should become familiar. One video laryngoscopy specific blade, the angulated blade, must be placed in the middle of the oropharynx without tongue displacement to view the vallecula. Providers then insert the ETT around the device during intubation. Another video specific blade, the anatomically shaped blade with guide channel, functions similarly to the angulated blade, but the ETT is preloaded into the guide channel and providers look for the vocal cords in the posterior aspect of the epiglottis during intubation.
Table 6. Complications with Endotracheal Intubation
- Oxygen desaturation
- Oral trauma/bleeding
- Esophageal intubation
- Mainstem intubation
- Vocal cord injury/avulsion
- Cuff leak
- Medication dosage errors
- Equipment failure
- Tube dislodgement
- Cardiac arrest
Studies evaluating video laryngoscopy in non-trauma pediatric, adult, and simulated patients have shown video laryngoscopy to improve visualization of the larynx, facilitate successful intubations, and provide rescue capabilities with difficult intubations.54-59 Benefits of video laryngoscopy over direct laryngoscopy in trauma patients remain controversial and studies evaluating patient outcomes are rare. Two studies involving adult trauma patients reported improved visualization of the tracheal entrance with reduced cervical spine movement using video laryngoscopy compared to direct laryngoscopy.60,61 A recent randomized controlled trial involving 623 adult trauma patients showed videolaryngoscopy by GlideScope to be associated with longer intubation times, but no difference in survival to hospital discharge among all patients studied.62 In a small cohort of patients with severe head injuries in the same study, however, GlideScope laryngoscopy was associated with a greater incidence of hypoxia to ≤ 80% and a higher mortality rate.62 Pediatric studies in trauma patients requiring intubation are few and results to date are similar to findings in adult studies. One study of 23 pediatric patients undergoing elective surgical procedures compared GlideScope to direct laryngoscopy with manual cervical spine immobilization to mimic conditions similar to trauma intubations.63 Laryngoscopy with GlideScope resulted in significantly decreased views to the glottis entrance as measured by glottic opening score and time to best view.63 Further evaluation of the efficacy and safety of video laryngoscopy, whether GlideScope or other video modalities, is needed in pediatric trauma patients to help guide the practice of intubation in scenarios requiring cervical spine immobilization.
Since there are no paradigms in place to guide the use of video laryngoscopy, providers must decide on a case-by-case basis whether to employ these devices when intubating in the ED setting.
Numerous studies confirm the safety and efficacy of pediatric RSI in the ED for both medicine and trauma patients requiring intubation. According to recent literature, the RSI approach to emergency intubation is associated with fewer attempts at laryngoscopy and better success at achieving endotracheal intubation.37,64 The Pediatric Emergency Medicine Committee of the American College of Emergency Physicians advocates for the use of RSI "in every emergency intubation involving a child with intact upper airway reflexes."8,9,37 RSI remains the method of choice for managing an emergent airway in the ED, and when conducted with the appropriate planning, positioning, and medications, intubation can be achieved with minimal complications (See Figure 1).
- Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf. Accessed March 25, 2014.
- Agrawal D. UpToDate June 2012.
- Tayal VS, et al. Acad Emerg Med 1999;6:31-37.
- Zelicof-Paul A, et al. Curr Opin Pediatr 2005;17:355-362.
- Dunham CM, et al. Guidelines for Emergency Tracheal Intubation Immediately Following Traumatic Injury: An EAST Practice Manage-ment Guidelines Workgroup. 2002.
- Hastings RH, Marks JD. Available at: www.trauma.org/index.php/main/article/377. Accessed March 25, 2014.
- McAllister JD, Gnauck KA. Pediatr Clin North Am 1999;46:1249-1284.
- Bledsoe GH, Schexnayder SM. Pediatr Emerg Care 2004;20:339-344.
- Gerardi MJ, et al. Ann Emerg Med 1996;28:55-74.
- Leonard JC, et al. Ann Emerg Med 2011;58:145-155.
- Yucesoy K, Yuksel KZ. Clin Neurol Neurosurg 2008;110:429-433.
- Aphrahamian C, et al. Ann Emerg Med 1984;13:584-587.
- Bivins HG, et al. Ann Emerg Med 1988;17:25-29.
- Majernick TG, et al. Ann Emerg Med 1986;15:417-420.
- Bingham RM, Proctor LT. Pediatr Clin North Am 2008;55:873-886.
- Weingart SD, Levitan RM. Ann Emerg Med 2012;59:165-175.
- Ramachandran SK, et al. J Clin Anesth 2010;22:164-168.
- Robinson N, Clancy M. Emerg Med J 2001;18:453-457.
- Hwang J, et al. Ann Emerg Med 2013;1:32-36.
- Takahata O, et al. Anesth Analg 1997;84:419-421.
- Samuel N, et al. Ann J Emerg Med 2012;9:2005-2010.
- Newth CJ, et al. J Pediatr 2004;
- Weiss M, et al. Br J Anesth 2009;103:867-873.
- James I. Paediatr Anesth 2001;11:259-263.
- Fastle RK, Roback MG. Pediatr Emerg Care 2004;20:651-655.
- Jones P, et al. Arch Dis Child 2012;97:139-144.
- Carroll CL, et al. Pediatr Crit Care Med 2010;11:343-348.
- McAuliffe G, et al. Can J Anesth 1995;42:724-729.
- PALS Provider Manual. American Academy of Pediatrics/American Heart Association; 2002.
- Frakes MA. J Emerg Nurs 2003;
- El-Orbany M, Connolly LA. Anesth Analg 2010;110:1318-1325.
- Ching KY, Baum CR. Pediatr Emerg Care 2009;25:200-210.
- Guldner G, et al. Acad Emerg Med 2003;10:134-139.
- Zuckerbraun NS, et al. Acad Emerg Med 2006;13:602-609.
- Sokolove PE, et al. Pediatr Emerg Care 2000;16:18-21.
- Hildreth AN, et al. J Trauma 2008;65:573-579.
- Hohl CM, et al. Ann Emerg Med 2010;56:105-113.
- Tekwani KL, et al. Acad Emerg Med 2009;16:11-14.
- Komatsu R, et al. Anesth Analg 2013;117:1329-1337.
- Yamamoto LG. In: Textbook of Pediatric Emergency Medicine, 6th edition. Philadelphia: Lippincott Williams and Wilkins; 2010:74-84.
- Filanovsky Y, et al. CJEM 2010;
- Bar-Joseph G, et al. J Neurosurg Pediatr 2009;4:40-46.
- Sehdev RS, et al. Emerg Med Australas 2006;18:37-44.
- Gnauck K, et al. Ann Emerg Med 1994;23:1242-1247.
- Shearer P, Riviello J. Emerg Med Clin North Am 2011;29:51-64.
- Riviello JJ Jr, et al. Neurocrit Care 2013;18:193-200.
- Testerman GM, et al. Am Surg 2011;12:1714-1715.
- Wong JM. Am J Ther 2010;17:487-491.
- Mallon WK, et al. J Emerg Med 2009;37:183-188.
- Martyn JA, Richtsfeld M. Anesthesiology 2006;104:158-169.
- Kerrey BT, et al. Ann Emerg Med 2012;60:251-259.
- Sagarin MJ, et al. Pediatr Emerg Care 2002;18:417-423.
- Reid C, et al. Emerg Med J 2004;
- Cooper RM, et al. Can J Anaesth 2005;52:191-198.
- Kim JT, et al. Br J Anaesth 2008;
- Redel A, et al. Paediatr Anaesth 2009;19:667-671.
- Nagler J, Bachur RG. Curr Opin Pediatr 2009;21:299-305.
- Aziz MF, et al. Anesthesiology 2011;114:34-41.
- Paolini JB, et al. Can J Anesth 2012;60:184-191.
- Bathory I, et al. Anaesthesia 2009;64:1337-1341.
- Robitaille A, et al. Anesth Analg 2008;106:935-941.
- Yeatts DJ, et al. J Trauma Acute Care Surg 2013;75:212-219.
- Vlatten A, et al. Pediatr Emer Care 2012;28:1317-1320.
- Walls RM, Murphy MF, eds. Manual of Emergency Airway Management. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.