Steps for emergency endotracheal intubation of a child

What are the steps for emergency endotracheal intubation of a child? 

Begin bag-valve mask ventilation with 100% oxygen as soon as the need for positive-pressure ventilation is identified. Emergency endotracheal intubations are generally treated as “full-stomach” intubations. The steps for a rapid sequence intubation are as follows:

• 1. Preoxygenate with bag-valve-mask ventilation with 100% oxygen.
• 2. Prepare all equipment, including suction, endotracheal tubes, and laryngoscopes.
• 3. Make certain an IV catheter is functioning well.
• 4. Administer atropine (for younger children and those receiving succinylcholine), followed by a sedative agent and then a paralytic agent.
• 5. Perform laryngoscopy once paralysis is complete, and watch the endotracheal tube go through the vocal cords into the trachea.
• 6. Auscultate for equal breath sounds and check for the presence of CO ₂ by capnometry. Observe symmetric chest expansion, misting in the tube with exhalation, and improvement in oxygen saturation by pulse oximetry, and listen for gurgling over the stomach, which suggests esophageal intubation.
• 7. Secure the tube with tape.
• 8. Evacuate the stomach with a nasogastric or orogastric tube.
• 9. Obtain a chest radiograph to check the position of the tube and adjust accordingly.

STEPS TO PERFORM ENDOTRACHEAL INTUBATION

• 1. Preoxygenate with 100% oxygen by bag-valve-mask device.
• 2. Prepare equipment (e.g., suction, endotracheal tubes, laryngoscopes, monitors—electrocardiogram [ECG], pulse oximeter, end-tidal CO ₂ detector or monitor).
• 3. Confirm functioning intravenous (IV) line.
• 4. Administer medications (atropine for younger children and those receiving succinylcholine, sedative, paralytic agent).
• 5. Intubate the trachea, observing the tube pass through the vocal cords.
• 6. Verify proper placement—auscultate the chest, check for CO ₂ by capnometry, chest radiograph.
• 7. Secure the endotracheal tube.
• 8. Evacuate the stomach with a nasogastric or orogastric tube.

Sources

American Heart Association: 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 14: Pediatric Advanced Life Support. Circulation 2010;122(18):876-908. 

King C, Rappaport LD. Emergent endotracheal intubation. In Henretig FM, King C (eds). Textbook of Pediatric Emergency Procedures 2nd Edition. Philadelphia, Wolters Kluwer/Lippincott, Williams & Wilkins 2008;146-190.