Suction Prepared and Under Pillow

RSI in a Child

RSI is used to secure the airway quickly with an endotracheal tube and to prevent chance of regurgitation and aspiration.

Technique;

- Preoxygenation (4 vital capacity breaths or until ETO2 is concentration >90%, this may be difficult with an uncooperative child, a cautious dose of fentanyl 0.25mcg/kg IV provides a slightly sedated more compliant child, caution needs to be taken as airway protection must be maintained, not normally a problem for small children, but older ones may kick up a fuss)

- Suction prepared and under pillow

- Induction with thiopentone 3-6mg/kg IV as long as patients haemodynamics will tolerate this dose

- Cricoid pressure applied by skilled assistance

- Suxamethonium 1-2mg/kg IV (2mg/kg for neonates, and 1mg/kg children)

- Once patient fasciculated -> rapid laryngoscopy with placement of a endotracheal tube (uncuffed until age 8, then cuffed) – leak should occur @ 20cmH2O if uncuffed

- check endotracheal tube placement by; observing tube fogging, chest rising and falling, auscultation of in both axillae and observing end tidal CO2, if child is >2 years old then endotracheal tube should be at lips by formula age/2 + 12cm.

- once endotracheal tube is satisfactory position cricoid pressure can be released

- if N/G insitu leave in place during procedure as will help decompress stomach if bag-mask ventilation required, remove post procedure if indicated

I prefer to use suxamethonium for the following reasons;

- rapid onset

- fasiculations are a easily observed where as NDNMBD don’t have such a clinical marker of onset

- rapid offset (therefore if I fail to secure airway spontaneous ventilation should return within 9 min unless patient has pseudocholinesterase deficiency)

- profound neuromuscular blockade and therefore very good intubating conditions

- if suxamethonium induces a bradycardia then this can be readily corrected with a small dose of atropine (20mcg/kg) – which I always have drawn up

- myalgias are less of a problem with small children

Problems

- preO2 difficult

- desaturation less

- less morbidity -> hypoxia

- no mortality (so far)

- sux problem

Jeremy Fernando (2011)