Rapid sequence intubation in children — OSCE

Station brief (candidate)

• Prepare the airway equipment and state the endotracheal tube size (uncuffed and cuffed) and laryngoscope blade for this child, showing your formula.
• State your induction agent, neuromuscular blocker, and premedication with doses, and justify the induction choice by the child's haemodynamic state.
• Describe how you would confirm tube placement and how you would manage a desaturation during laryngoscopy.
• Outline the post-intubation care, including sedation and monitoring. [1] [3]

Scenario detail

The child is a 3-year-old (15 kg) with severe viral pneumonia, tiring over the last hour, with saturations of 86 per cent on high-flow oxygen, marked recession, and increasing drowsiness. The circulation is intact (warm peripheries, normal capillary refill, good pulses). You have been asked to lead the intubation. The examiner will ask you to talk through your preparation and then probe a complication. [6]

Expected candidate performance

1. Equipment preparation: Names suction, oxygen and bag-mask, a checked laryngoscope with the correct blade and a spare, the sized tube plus half-sizes above and below, a bougie or stylet, a supraglottic airway, and a carbon dioxide detector. [1]
2. Tube sizing and blade: States the formulae clearly — uncuffed (age/4) + 4 = 4.75 mm, round to a 5.0 mm; cuffed (age/4) + 3.5 = 4.25 mm, round to a 4.5 mm — and selects a curved Macintosh 2 blade for this age. [3]
3. Drug choice and dose: Preoxygenates with 100 per cent oxygen for three minutes; chooses an appropriate induction agent (for a cardiovascularly stable child, propofol 2 to 4 mg/kg IV or ketamine 1 to 2 mg/kg IV are both defensible), paralyser (suxamethonium 1 to 2 mg/kg IV or rocuronium 1 mg/kg IV), and atropine 20 micrograms/kg IV premedication, giving induction and paralyser in rapid succession. [3]
4. Confirmation and desaturation: Confirms with exhaled carbon dioxide plus bilateral air entry and chest rise; states that if the child desaturates they will stop, return to bag-mask ventilation with oxygen, reposition and reattempt, rather than persist. [6]
5. Post-intubation care: Secures the tube, starts lung-protective ventilation, gives ongoing sedation and analgesia (a paralysed child must be sedated), arranges a chest radiograph, and admits to paediatric intensive care. [3]
6. Complication management: Names the DOPE sequence for a deteriorating intubated child and the correct first action — disconnect and hand-ventilate with 100 per cent oxygen while checking the tube. [3]

Marking domains

• Complete equipment and drug preparation stated before the procedure, with correct tube sizing by formula.
• Induction agent justified by haemodynamic state with correct weight-based doses.
• Mandatory carbon dioxide confirmation and a safe, correct response to desaturation.
• Post-intubation sedation, analgesia and monitoring not forgotten.
• Recognition and first action for the deteriorating intubated child. [1] [6]

Common fails

• Choosing a full dose of propofol for a shocked child without recognising the cardiovascular risk. [3]
• Forgetting atropine premedication in a young child, or being unable to give its dose and indication. [5]
• Persisting with laryngoscopy during desaturation instead of returning to bag-mask ventilation. [6]
• Leaving the child paralysed without sedation or analgesia, or omitting carbon dioxide confirmation. [3]