Pediatric Rapid Sequence Intubation Medication Regimen

Introduction to Pediatric RSI

The American Academy of Pediatrics recommends a sedative-hypnotic agent (ketamine or etomidate) followed by a neuromuscular blocking agent (succinylcholine or rocuronium), with atropine pretreatment for children under 8 years of age 1, 2

Atropine should be administered during induction and before intubation for children aged from 28 days to 8 years, particularly in those with septic shock, hypovolemia, or when succinylcholine is used 2
The recommended atropine dosing is 0.01-0.02 mg/kg IV (maximum: 0.5 mg) 3
Atropine helps prevent bradycardia that can occur during laryngoscopy or from succinylcholine use in pediatric patients, with a strength of evidence level of high 4

Ketamine is recommended as a first-line agent for pediatric RSI, especially in hemodynamically unstable patients, with a dosing of 1-2 mg/kg IV 1, 2, 5
Ketamine maintains hemodynamic stability through sympathomimetic effects, with a strength of evidence level of moderate 6
Etomidate is an alternative first-line agent, particularly useful in patients with head injury, with a dosing of 0.2-0.4 mg/kg IV (maximum: 20 mg) 1, 3
Etomidate has minimal hemodynamic effects and lowers intracranial pressure, with a strength of evidence level of high 3

Succinylcholine is the first-line neuromuscular blocking agent for RSI in pediatric patients with respiratory or cardiovascular compromise, with a dosing of 1-1.5 mg/kg IV for children >10 years; 1.2 mg/kg for children 1-10 years; 2.0 mg/kg for infants 1 month to 1 year; 1.8 mg/kg for neonates <1 month 1, 2
Rocuronium is recommended when succinylcholine is contraindicated, with a dosing of 0.9-1.2 mg/kg IV 1, 2
Sugammadex should be rapidly available when rocuronium is used for potential reversal if needed, with a strength of evidence level of high 1

For patients with increased intracranial pressure, consider lidocaine 1-2 mg/kg IV as a single dose 30 seconds to 5 minutes before airway instrumentation, with a strength of evidence level of low 5
For hemodynamically unstable patients, ketamine is preferred over other induction agents due to its relative hemodynamic stability, with a strength of evidence level of moderate 2, 6

Failure to administer atropine in young children, particularly when using succinylcholine, increasing the risk of clinically significant bradycardia, with a strength of evidence level of high 2, 4
Using succinylcholine in patients with contraindications such as hyperkalemia, which can lead to cardiac arrest, with a strength of evidence level of high 4
Failure to have sugammadex available when using high-dose rocuronium, which may be needed in a "can't intubate, can't ventilate" scenario, with a strength of evidence level of high 1, 6

Propofol is not recommended for hemodynamically unstable patients due to hypotensive effects, according to the American College of Emergency Physicians 7