🫁 Chapter 20: Intubation & RSI in Children

Rapid Sequence Intubation (RSI) · Drug selection (ketamine, etomidate, succinylcholine, rocuronium) · Apnoeic desaturation · ETT sizing · Difficult airway predictors · Post-intubation management

🔍 Core Concepts: Intubation & RSI in Children

🆘 Indications for intubation
Airway protection, facilitation of positive-pressure ventilation, controlled ventilation for cerebral oedema, optimal conditions for procedures.
⚡ RSI components
Rapid administration of anaesthetic agent + muscle relaxant to achieve ideal intubating conditions, attenuate reflexes, minimize aspiration risk (no bag-mask ventilation if possible).
💊 Preferred RSI drugs
Ketamine (cardio-stable, bronchodilator) or etomidate (cardio-stable, adrenal suppression concern). Succinylcholine (rapid onset, short duration) or rocuronium (60-90 sec onset, longer acting).
📏 Paediatric airway differences
Higher airway (C1 infant), large tongue, cricoid ring narrowest, prominent occiput. Sniffing position (shoulder roll <3y, occiput roll >3y).
📐 ETT size estimation
Uncuffed: 4.5 + age/4; Cuffed: 3.5 + age/4. Length (cm): 12 + age/2. Confirmation: EtCO2, equal chest rise, CXR tip at T2.
⚠️ Modified RSI
In hypoxaemic patients: bag-mask ventilation before muscle relaxant to saturate FRC. Avoid prolonged apnoea. Always have difficult airway kit ready.

🩺 Stepwise Approach: RSI & Intubation in Children

1
Preparation (SOAPME)
Suction, Oxygen (100% preoxygenation), Airway equipment (blades, tubes, LMA), Pharmacology (drugs drawn), Monitoring (ECG, SpO2, EtCO2), Equipment (difficult airway kit).
2
Positioning & preoxygenation
Sniffing position: shoulder roll for <3 years, occiput roll for >3 years. Preoxygenate with non-rebreather or NIPPV for 3-5 minutes. For hypoxaemic, consider modified RSI with bag-mask ventilation.
3
Drug selection (anaesthetic + muscle relaxant)
Haemodynamically stable: ketamine (1-2 mg/kg) or etomidate (0.2-0.3 mg/kg) + rocuronium (0.6-1.2 mg/kg) or succinylcholine (1-2 mg/kg). Hypotensive/shock: ketamine preferred. Raised ICP: thiopentone/propofol + lignocaine.
4
RSI technique & intubation
Apply cricoid pressure (full stomach). No bag-mask ventilation unless hypoxaemic. Laryngoscopy after 45-60 sec (rocuronium) or 30-45 sec (succinylcholine). Confirm tube position: EtCO2 + auscultation + CXR.
5
Post-intubation management
Secure ETT, initiate sedation/analgesia (fentanyl + midazolam or dexmedetomidine). Set initial ventilator settings (TV 6-8 mL/kg, rate age-appropriate). Obtain CXR to check ETT tip at T2.
6
Special scenarios
Difficult airway: awake intubation, fibre-optic, ENT backup. Cardiac arrest: no RSI, intubate during CPR. Status asthmaticus: ketamine + glycopyrrolate, avoid hyperinflation.