Rapid sequence intubation in children — viva

Opening (must-hit)

"Rapid sequence intubation is a planned sequence in which I render a child unconscious and paralysed in rapid succession and pass an endotracheal tube without mask ventilation in between, because the child is assumed to have a full stomach. I prepare a team and equipment first, preoxygenate to the child's shorter safe apnoea time, size the tube by the age formulae, and confirm placement with exhaled carbon dioxide. I choose the induction agent to the child's haemodynamics and give atropine premedication to the youngest children. I never persist with a blind attempt if the child desaturates, and I never leave a paralysed child without sedation." [1] [3] [6]

Branch A — Tube sizing and blade choice

Examiner: A 6-year-old needs intubation. What tube size and blade do you prepare? Candidate: The uncuffed tube internal diameter in mm is age over four plus four, so (6/4) + 4 = 5.5 mm; the cuffed tube is age over four plus 3.5, so 5.0 mm. I have a half-size above and below ready. For the blade, a young child takes a curved Macintosh 2; the straight Miller blade is for neonates and infants, whose long stiff epiglottis must be lifted directly. [3]

Branch B — The shocked child

Examiner: The child is in septic shock, cold and shut down. How does that change your drugs? Candidate: It changes everything. A full dose of propofol or thiopentone can collapse the blood pressure and precipitate arrest in a catecholamine-depleted child. I choose ketamine 1 to 2 mg/kg IV for its sympathetic preservation, or etomidate 0.3 mg/kg IV, and I have a fluid bolus and a vasoactive infusion ready to run at the moment of induction. I reduce the induction dose if the shock is profound. [3] [4]

Branch C — Bradycardia on laryngoscopy

Examiner: The infant's heart rate drops to 50 during the attempt. Why, and what do you do? Candidate: Laryngoscopy and suxamethonium provoke a vagal bradycardia, and infants are the most vulnerable. I stop the stimulus, ventilate with 100 per cent oxygen, and if it persists give adrenaline. To prevent it I give atropine 20 micrograms/kg IV (minimum 100 micrograms) as premedication to infants under one year and to young children receiving suxamethonium. [5]

Branch D — Choosing the paralyser

Examiner: How do you choose between suxamethonium and rocuronium? Candidate: Suxamethonium 1 to 2 mg/kg IV has the fastest onset and shortest duration, which suits a predicted difficult airway where I want the child breathing again quickly, but it risks hyperkalaemia in neuromuscular disease, burns, and renal failure, and can trigger malignant hyperthermia. Rocuronium 1 mg/kg IV has a rapid onset without those risks and is reversible by sugammadex. I avoid suxamethonium in any child with a hyperkalaemia or malignant-hyperthermia risk. [4]

Branch E — Desaturation during the attempt

Examiner: The saturations fall to 80 per cent on your first laryngoscopy. What now? Candidate: I stop, abandon the attempt, and return to bag-mask ventilation with 100 per cent oxygen. I reposition the child, suction if there are secretions, and reattempt once the saturations recover. Persisting with a blind or prolonged laryngoscopy while the child is hypoxaemic is the dangerous error; bag-mask ventilation in RSI is acceptable and correct when the child desaturates. [6]

Branch F — The difficult airway

Examiner: The child has a small jaw and a short neck. What is your plan before you paralyse? Candidate: I treat this as a predicted difficult airway. I call senior anaesthetic help, prepare a video laryngoscope, have a supraglottic airway sized to the child and ready, and state the failed-airway plan aloud: if I cannot intubate and cannot oxygenate, I place a supraglottic airway, and if that fails I proceed to a needle cricothyroidotomy in a small child. I do not paralyse until the back-up is in the room. [3]

Branch G — After the tube is in

Examiner: The tube is placed and the carbon dioxide trace is good. What now? Candidate: I secure the tube, start lung-protective ventilation, and give ongoing sedation and analgesia — a paralysed child must be sedated and given analgesia. I arrange a chest radiograph to confirm the tube tip sits above the carina, and I admit the child to paediatric intensive care. I keep capnography continuous from here on, because the tube can migrate or dislodge at any point. [3]