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Controversies in rapid sequence intubation in children

Zelicof-Paul, Audreya; Smith-Lockridge, Arlenea; Schnadower, Davida; Tyler, Saraha; Levin, Serleb; Roskind, Cindya; Dayan, Petera

Current Opinion in Pediatrics: June 2005 - Volume 17 - Issue 3 - p 355-362
doi: 10.1097/01.mop.0000162365.64140.b7
Emergency and critical care medicine

Purpose of review Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children.

Recent findings The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics,

  • The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients.
  • Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation.
  • Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure.
  • Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine.

Summary Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.

aDepartment of Pediatrics, Emergency Division, The Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York, USA, and bDepartment of Anesthesia, White Plains Hospital Center, White Plains, New York, USA

Correspondence to Peter Dayan, MD, MSC, The Children's Hospital of New York-Presbyterian, 622 W. 168th St., PH 137, New York, NY 10032, USA

Tel: 212 305 8595; fax: 212 305 6792; e-mail:

© 2005 Lippincott Williams & Wilkins, Inc.