Preparation – Utilize an active checklist to: |
Begin preoxygenation as described below. |
Identify conditions that will affect choice of medications (eg, increased intracranial pressure, septic shock, bronchospasm, status epilepticus, or, if succinylcholine use is planned, absolute contraindications for its use as listed below). |
Identify conditions that will predict difficult intubation or bag-mask ventilation (eg, small chin, inability to fully open the mouth, upper airway trauma, or infection). |
Assemble equipment and check for function. |
Develop contingency plan for failed intubation (refer to UpToDate topics on devices for difficult endotracheal intubation). |
Preoxygenation |
Begin preoxygenation as soon as rapid sequence intubation is potentially needed:
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Administer oxygen at the highest concentration available. |
Pretreatment (optional) |
Atropine: Although not routinely recommended, many experts suggest atropine as pretreatment for:
Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 1 mg; if no IV access, can be given IM). |
Induction (sedation) |
Etomidate:
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Ketamine:
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Propofol:
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Midazolam:
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Fentanyl:
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Paralytic |
Rocuronium:
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Succinylcholine:
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Protection and positioning |
Maintain manual cervical spine immobilization during intubation in the trauma patient. |
If cervical spine injury is not potentially present, put the patient in the "sniffing position" (ie, head forward so that the external auditory canal is anterior to the shoulder and the nose and mouth point to the ceiling). |
Utilize external laryngeal manipulation or, in infants, gentle cricoid pressure to optimize the view of the glottis during direct laryngoscopy if the initial view is suboptimal or inadequate despite correct laryngoscope blade positioning.Δ |
Positioning, with placement |
Confirm tracheal tube placement with end-tidal CO2 detection and auscultation. |
Postintubation management |
Obtain a chest radiograph to confirm the depth of tracheal tube insertion. |
Provide ongoing sedation (eg, midazolam), analgesia (eg, fentanyl 1 mcg/kg), and, if indicated, paralysis.◊ |
IM: intramuscularly; IV: intravenously; CO2: carbon dioxide; FiO2: fraction of inspired oxygen.
* Sugammadex in a dose of 16 mg/kg can provide immediate reversal of paralysis when given approximately 3 minutes after a single dose of rocuronium or vecuronium. Vecuronium may be used in children with contraindications to succinylcholine and when rocuronium is not available. Suggested dose for rapid sequence intubation: vecuronium 0.15 to 0.2 mg/kg. Patients may experience prolonged and unpredictable duration of paralysis at this dose.
¶ Defasciculating agents (eg, rocuronium or vecuronium at one-tenth of the paralyzing dose) are not routinely recommended for children receiving succinylcholine. Onset of paralysis is slower by the IM route; the clinician must ensure full pre-oxygenation prior to administration, whenever possible, and be prepared to perform bag-mask ventilation if desaturation occurs before the patient is fully paralyzed for endotracheal intubation.
Δ Bimanual laryngoscopy, also called external laryngeal manipulation (ELM), entails manipulating the thyroid cartilage or hyoid bone with the right hand during laryngoscopy in order to improve the view of the glottis. For a description of how to perform ELM, refer to UpToDate topics on emergency endotracheal intubation in children and rapid sequence intubation in children.
◊ If decompensation occurs after successful intubation, use the DOPE mnemonic to find the cause:Do you want to add Medilib to your home screen?