Paeds · acute-care-resuscitation-and-toxicology
Rapid sequence intubation in children
Also known as Paediatric RSI · Drug-assisted intubation in children · Crash airway management in children · Emergency endotracheal intubation in children
A fellowship approach to rapid sequence intubation in children: prepare a team and equipment, preoxygenate to a child's shorter safe apnoea time, give a weight-based induction agent and neuromuscular blocker in rapid succession, size the endotracheal tube by the age formulae (uncuffed equals age over four plus four; cuffed equals age over four plus 3.5), confirm placement with exhaled carbon dioxide, and avoid the pitfalls of desaturation, bradycardia and cardiovascular collapse.
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- Rising heart rate followed by bradycardia during laryngoscopy — vagal response to hypoxia and airway stimulation, arrest is imminent
- Oxygen saturation falling during an intubation attempt with no plan to return to bag-mask ventilation
- Need for three or more laryngoscopy attempts — adverse events rise sharply with each attempt
- Cardiovascular collapse after induction in a child who was in shock — full-dose propofol or thiopentone given to a catecholamine-depleted child
- Paralysed child with no sedation or analgesia and no post-intubation plan
- Loss of end-tidal carbon dioxide after the tube is secured — dislodgement, kink or oesophageal placement
- Asymmetric chest movement and unilateral breath sounds after intubation — right mainstem intubation
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- Acute and emergency assessment
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- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
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A 3-year-old with severe pneumonia is grunting, retracting hard, and now drowsy with saturations of 86 per cent on high-flow oxygen. You have decided she needs a definitive airway. The next ten minutes are where children are made safe or harmed, because a child's oxygen reserve is small, the doses are weight-based and unforgiving, and the difference between a calm first pass and a frantic third attempt is preparation. This page teaches the whole sequence — the drugs, tube sizes, blade choices, and what to do when it goes wrong. [1] [6]
Preparation (team, kit, drugs, plan) · Preoxygenation (100% O2, 3 min or 8 breaths) · Pretreatment (atropine) · Paralysis with induction (ketamine + sux or rocuronium) · Positioning (sniffing) · Placement with proof (laryngoscopy, ETT, CO2) · Post-intubation care (secure, sedate, ventilate, confirm). [1] [3]
Overview & Definition
Imagine you must put a breathing tube into a sick child in the next two minutes. The child has not fasted, so stomach contents could come up the oesophagus and go down lungs moment they lose consciousness. Rapid sequence intubation is the technique built to beat that risk. You give an induction drug to make the brain unconscious and a neuromuscular blocker to stop breathing and muscle tone almost at the same moment, then pass the tube as quickly as possible without squeezing the bag in between, because bagging pushes air into the stomach and forces regurgitation. [1]
The word "rapid" refers to the sequencing of the two drugs and the deliberate omission of mask ventilation — not to a reckless hurry. Every step is prepared in advance so that the apnoeic interval between loss of consciousness and tube placement is as short as you can make it. Sagarin and colleagues framed RSI for the paediatric emergency setting as a structured, drug-assisted intubation that an emergency team can perform reliably under pressure. [1]
The key idea a candidate must hold is the buffer. In an elective anaesthetic intubation you preoxygenate, paralyse, and if the view is poor you mask-ventilate the patient while you get a better look, because the patient is fasted and you have time. In RSI you give up that mask-ventilation safety net on purpose, in exchange for protecting the lungs from aspirated gastric contents. That trade only works if you have done the preparation that lets you pass the tube quickly and confirm it, and if you have a back-up plan for moment tube will not go in. [3]
References12ShowHide
- [1]Sagarin MJ Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care, 2002.PMID 12488834
- [2]Khine HH Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology, 1997.PMID 9066329
- [3]Zelicof-Paul A Controversies in rapid sequence intubation in children. Curr Opin Pediatr, 2005.PMID 15891426
- [4]Ching KY Newer agents for rapid sequence intubation: etomidate and rocuronium. Pediatr Emerg Care, 2009.PMID 19287283
- [5]Fastle RK Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care, 2004.PMID 15454737
- [6]Kerrey BT Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med, 2012.PMID 22424653
- [7]De Orange FA Cuffed versus uncuffed endotracheal tubes for general anaesthesia in children aged eight years and under. Cochrane Database Syst Rev, 2017.PMID 29149469
- [8]Goto T Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department. West J Emerg Med, 2016.PMID 26973736
- [9]Kim JH Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study. Children (Basel), 2022.PMID 35883944
- [10]Kovacich NJ Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department. Pediatr Emerg Care, 2022.PMID 34009889
- [11]Abid ES The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team. Prehosp Emerg Care, 2021.PMID 32347776
- [12]Mendez D Succinylcholine Versus Rocuronium for Pediatric Rapid Sequence Intubation in the Emergency Department. Pediatr Emerg Care, 2026.PMID 41489184