EM Notes – Paediatric RSI


  1. Worsening pulmonary function tests despite vigorous bronchodilator therapy
  2. Decreasing PaO2
  3. Increasing PaCO2
  4. Progressive respiratory acidosis
  5. Declining mental status
  6. Increasing agitation


  1. Spontaneous breathing with adequate ventilation
  2. operator concerned that both intubation & mask ventilation may not be successful
  3. Major laryngeal trauma
  4. Upper airway obstruction
  5. Distorted facial or airway anatomy


  1. Assess risks
    1. AMPLE history & examination of the neck, face, head nose & chest
  2. Minimum equipment for RSI
    1. Appropriate sized bag-valve mask with reservoir
    2. Suction (fully hooked up and functional)
    3. Oxygen (hooked up to bag-valve mask)
    4. Laryngoscope with appropriate size blades and functioning lights
    5. Appropriately sized ETT (with one size smaller & larger) + stylet for ETT ± boogie
    6. All pharmaceutical agents to be used where intubation is planned
    7. Alternative airway equipment in location where intubation is planned


  1. Most senior or experienced member of staff to do procedure
  2. Use a stylet to facilitate intubation
  3. Straight laryngoscope blades should be used up to the age of 4-5 years
  4. Intubation technique
    1. Similar to that in the adult. Always have ready a tube one size smaller and a tube one size larger ready
    2. Ensure appropriate monitors (HR, BP, pulse oximeter)
    3. Pre-oxygenation is critical
    4. Position is key – Child’s trachea takes off from the oral cavity at a 45 degree angle
    5. Pre-medicate with Atropine if necessary
    6. Administer appropriate sedative agent (ketamine)
    7. Apply cricoid pressure (Sellick manoeuvre)
    8. Administer neuromuscular blocking agent (suxamethonium)
    9. Advance tube until it goes through the cords and advanced another 1-2 cm
    10. Determine accurate placement (end-tidal CO2, oesophageal detector device)
    11. Secure the tube firmly

Outcomes – Verified placement

  1. Visualisation of tubes passage through the cords
  2. Auscultation of bilateral breath sounds and absence of bubbling over stomach
  3. Observation bilateral chest movement
  4. Maintenance of good pulse oximetry readings after intubation in paralysed patient
    1. False negative – if profoundly shocked or inadequate chest compressions
  5. Appropriate waveform and quantitative measurement of ETCO2
    1. False positive – if mouth-to-mouth resuscitation or pt has had carbonated drinks
  6. Chest x-ray
    1. Portable AP can miss of oesophageal intubation if oesophagus & trachea aligned


  1. Oesophageal intubation
  2. R main bronchus intubation
  3. Hyperventilation & barotrauma after intubation
  4. Can’t intubate ± can’t ventilate
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