Procedures, Monitoring, Resuscitation, and Transport
Airway and procedures
Rapid sequence intubation requires preoxygenation, optimized hemodynamics, a premedication plan, and a confirmed end-tidal carbon dioxide trace. Ketamine preserves hemodynamics; etomidate provides stability but can suppress adrenal function. Rocuronium 1.2 mg/kg provides rapid paralysis. Atropine 0.02 mg/kg (minimum 0.1 mg) is given to infants receiving succinylcholine. Estimate uncuffed tube size as age/4 + 4, and insertion depth as three times the tube size. Intraosseous access is appropriate for any decompensated child without rapid intravenous access.
Resuscitation
Compression rate is 100-120 per minute with depth of one third of the anteroposterior chest diameter and a 15:2 ratio for two rescuers. Defibrillate at 2 J/kg, then 4 J/kg, up to 10 J/kg. Post-arrest care includes targeted temperature management, avoiding hypotension and hyperoxia, and treating the cause.
Monitoring and transport
Capnography, arterial lines, central venous pressure, and ultrasound all require interpretation in context. Transport preparation includes securing the airway, checking tubes and drains, ensuring adequate oxygen supply, and anticipating that altitude lowers inspired oxygen and expands gas-filled spaces. Use checklists and closed-loop communication.
Traps
A normal waveform on capnography does not confirm tube depth. Do not give repeated doses of an induction agent to a hypotensive child. Pneumothorax and ileus worsen during air transport. Failure to plan for battery life and spare equipment is a common transport pitfall.
Worked rule
A 4-year-old needs an uncuffed tube of 4/4 + 4 = 5.0 mm, with insertion depth of about 15 cm, confirmed by auscultation and capnography.