Rapid Sequence Intubation in Children

Pre-treatment

The American Academy of Pediatrics recommends atropine administration in all children from 28 days to 8 years of age, especially in those with septic shock, hypovolemia, or when succinylcholine is used 1
Atropine dose: 0.01-0.02 mg/kg IV (maximum: 0.5 mg) 1
Atropine prevents bradycardia during laryngoscopy or succinylcholine use in pediatric patients 1
Lidocaine 1-2 mg/kg IV may be considered 30 seconds to 5 minutes before airway instrumentation in patients with elevated intracranial pressure 2, 1

Ketamine is the first-line agent for pediatric rapid sequence intubation, especially in hemodynamically unstable patients 3, 4, 1
Ketamine dose: 1-2 mg/kg IV 1
Alternative ketamine dose: 3-4 mg/kg before 18 months of age; 2 mg/kg after 18 months 3, 4
Ketamine maintains hemodynamic stability through sympathomimetic effects 1
Etomidate dose: 0.2-0.4 mg/kg IV (maximum: 20 mg) 1
Etomidate is the first-choice agent in children over 2 years old, except in sepsis 3, 4
Etomidate has minimal hemodynamic effects and reduces intracranial pressure 1
Propofol dose: 2-4 mL/kg of appropriate solution 5
Propofol is used preferentially in elective procedures 3, 4

Succinylcholine is the first-line agent for rapid sequence intubation in children with respiratory or cardiovascular compromise 3, 4, 1
Succinylcholine dose: 1-1.5 mg/kg IV for children over 10 years old; 1.2 mg/kg IV for children 1-10 years old; 2.0 mg/kg IV for infants 1 month to 1 year old; 1.8 mg/kg IV for neonates under 1 month 1
Rocuronium dose: 0.9-1.2 mg/kg IV when succinylcholine is contraindicated 3, 4, 1, 6
Sugammadex should be readily available when rocuronium is used 3, 4, 1

Personnel with airway management skills should be present when rocuronium is administered 6
Age-appropriate equipment for aspiration, oxygenation, intubation, and ventilation should be immediately available 6
Continuous oxygen saturation monitoring is recommended 2