Rapid sequence intubation of the pediatric patient. Fundamentals of practice

Rapid-sequence intubation and rapid sequence induction of general anesthesia are synonyms and refer to the technique of choice for tracheal intubation in many pediatric patients in the emergency department. The principles of safe practice and basic standards of care uniformly apply to all clinical situations in which the technique is performed. RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation. The technique is a prescribed protocol that can be modified slightly by the clinical circumstances. RSI is designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses to direct laryngoscopy and tracheal intubation, and reduce the risk for pulmonary aspiration. Optimal performance requires appropriate training and knowledge, technical skill, and sound medical judgment. Medical and airway evaluation, careful patient selection, recognition of the need for consultation or safer alternatives, thorough familiarity with appropriate drug management, and attention to detail are essential for minimizing the risk for adverse complications. RSI with a rapid injection of preselected dosages of an anesthetic induction agent and muscle relaxant is the pharmacologic technique of choice. Premedication should not be routinely used. Anticipation, recognition, and management of complications are inherent to the competent delivery of all medical care. The unanticipated difficult airway is arguably the most severe complication of RSI, and all individuals performing the technique must prepare in advance a specific plan for this scenario. As with all such skills or procedures, a quality assurance program is important to monitor care, and individuals practicing RSI need to take appropriate steps to maintain competence.