For a great review article of RSI in children check out the following article:
- BJA Educ (2016) 16 (4): 120-123 Place of rapid sequence induction in paediatric anaesthesia. R Newton, H Hack
Predicting difficult airways in children:
Some key pearls when intubating an infant or small child:
- The HEMS paediatric bougie is too big for an ETT less than a 5.0
- If you’re using a straight blade (Miller) then prepare a straight tube (using a stylet) – the natural curve of the ETT is not helpful in this situation.
- Consider inserting the tip of your laryngoscope blade into the R of the valecula – when used in conjunction with ELM (external laryngeal manipulation) this will often allow a great view of the cords.
- Tying the ETT (with tape) centrally will reduce ETT movement (from side to side head movement) and the consequent risk of peri-laryngeal tip dislodgement BUT suctioning the oropharynx or re-inspection of tube placement with a laryngoscope is more difficult. The reverse balance of costs/benefits exists if the ETT is taped to the side of the mouth.
Peri-intubation management is of even higher priority in the care of sick children. Being prepared for a difficult airway is good but a haemodynamically unstable child during RSI is more likely:
- Rigorous CRM/Human Factors practice
- Optimisation of patient position (T-pod under the torso)
- Optimisation of your surroundings (people, environment, resources, a tidy kit dump will save you stress in the heat of the moment!)
- Optimisation of the patient physiology – see the NSW Health Guideline on Paediatric IV Fluid Management
It’s not all about the airway! When treating children we must pay attention to our little patients. This means creating as calm & reassuring an atmosphere as possible with the aide of parents/caregivers as well as paying close attention to the relief of pain. Consider the following take home points and see Natalie’s excellent post for further detail:
- Pain is more than nociception
- Be creative, thoughtful and flexible with your drug-based approach
- Consider all routes of administration
- Distraction is key!
- Address the wider factors affecting pain response