Guidelines for Rapid Sequence Intubation (RSI) in the Traumatically Injured Child

Definition:

A rapid controlled method to facilitate endotracheal intubation that minimizes the complications associated with intubation.

Rationale:

To provide adequate oxygenation, reduce aspiration risk, prevent cardiovascular instability, and prevent intracranial hypertension related to intubation.

Protocol:

1. Maintain in-line cervical spine immobilization.

2. Evaluate for any contraindications to rapid sequence intubation (relative contraindications may include upper airway obstruction, "difficult" airway, and hemorrhage obscuring vocal cord visualization).

3. Prepare intubation equipment, suction, monitors, and medications.

4. Preoxygenate child for 2-5 minutes with 100% oxygen. Use positive pressure ventilation with bag valve mask only in apneic patients.

5. Apply cricoid pressure.

6. Pretreat:

a) Lidocaine: 1.5 mg/kg if suspected head injury (administer two minutes prior to succinylcholine).

b) Atropine: .02 mg/kg if child is less than 6 years of age to reduce reflex bradycardia.

7. Administer etomidate 0.3 mg/kg. (Rationale: rapid onset, cerebro-protective effect, minimizes cardiovascular instability.)

8. Administer succinylcholine 2 mg/kg: allow 45-60 seconds for muscle relaxation. (Rationale: rapid onset less than 45 seconds; short duration of action less than 10 minutes.)

9. Place endotracheal tube.

10. Release cricoid pressure.

11. Clinically assess for proper tube placement (adequate rise and fall of the chest, bilateral breath sounds, mist in the endotracheal tube, adequate oxygen saturation, and end-tidal carbon dioxide detection).

12. Reposition tube, and reconfirm proper endotracheal tube placement as necessary.

Source: Cincinnati Children’s Hospital.