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Rapid Sequence Induction and the Difficult Airway Module


TopicRSI and the difficult airway
AuthorRobyn Goodier
DurationUp to 2 hrs
Equipment requiredCan be done without equipment, however for interactivity it would be useful to have different laryngoscopes/ETT/bougie/stylet etc for demonstration purposes.
  • Basics – including airway plans and assessment (30 mins)
  • Main session: (2 x 15 minute) case discussions 
  • Advanced session: (2 x 20 minutes) case discussions covering more controversial settings
  • Sim scenario – optional (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Paediatric airway compromise requiring emergency management by rapid sequence induction (RSI) is a rare event in the Emergency Department. However, despite it being rare, it is associated with high mortality and morbidity with an overall death rate of 3.8%, the highest for a critically unwell child

Airway securement is a procedure that every critical care physician should be competent in performing. 

So what do we mean when we say RSI?

What are the indications for an RSI?

The 12 Ps of RSI

Robert is a 7 year old boy seen in ED with a cough for 5 days, increasing shortness of breath and fevers. Mum brought him to ED as he was lethargic and breathing quickly. On examination he is lethargic with dry mucous membranes, in respiratory distress with a rate of 45, saturations of 92% on 15L oxygen. He is persistently hypotensive despite 40ml/kg fluids. He is becoming bradycardic and his GCS is now 9. You are worried he is in septic shock with impending respiratory failure and circulatory collapse. You decide to proceed to an emergent RSI.

How can he be optimized physiologically before RSI?

Would you start inotropes?

What is your induction agent of choice for RSI in these haemodynamically compromised children? 

How can he be optimised physiologically?

What would be your induction agent of choice here?

Jeremy is a 10 year old boy brought in by ambulance after falling off his BMX at a skate park doing a jump without a helmet on. He had a fall from approximately 2 metres onto his head. He had an initial LOC for 2 minutes then was ok, but since then he has had multiple vomits and become drowsy. The ambulance have issued a pre arrival phone call as they are concerned he has a reduced GCS of 8 but no evidence of raised ICP at this stage. The ambulance crew have immobilised his C Spine.

You decide to prepare for an RSI before the child arrives as it seems he will need a secure airway.

How do you do an RSI with a C spine collar on?

His friend tells you they went to McDonalds 2 hours prior to this happening. Would you alter your approach knowing this information? Would you ask for cricoid pressure? 

What is your choice of induction agent and why?

How do you do an RSI with a c spine collar on?

He ate a McDonald’s two hours ago. How would that change your approach? Would you use cricoid pressure?

What would your choice of induction agent be?

Ashleigh is a 2 year old female brought in to you on New Year’s Eve after her sister accidentally let off a firework that exploded in her face.

Ashleigh has obvious burns to her face/neck/chest/upper limbs. When you perform an airway assessment you can hear soft stridor and see burns inside her mouth.

You decide that she has a threatened airway and decide to intubate her. 

Your consultant decides to use suxamethonium as the muscle relaxant of choice. You ask why because you heard it was contraindicated in burns. What is the evidence surrounding use of suxamethonium in burns?

You find yourself in a CICO situation after failed intubation and LMA placement. What is your difficult airway plan for this 2 year old? 

Why is expectant airway management in burns so important?

What is the evidence around suxamethonium in burns?

What is your difficult airway plan for this patient?

Why is expectant management ofr burns so important?

Lily is a 2 month old infant being brought into ED by her mum as she is not feeding well and she has noticed her breathing is abnormal. She has an unremarkable birth history, born at term via NVD, GBS negative, Apgars 9 +9.

She has an older brother Isaac who attends daycare and has a runny nose recently. 

Lily is in respiratory distress with grunting, nasal flaring, recession and head bobbing. You have tried HFNP and CPAP to little avail over the past 3 hours. She is now tiring and is becoming bradypnoeic and bradycardic. To prevent cardiac arrest you decide to intubate this child so proceed to an RSI. 

Does this child need atropine preloading? Do all children need atropine?

Would you use a cuffed or uncuffed ETT?

Would you use a bougie?

Would you give atropine preloading?

Would you use a cuffed or uncuffed tube?

Would you use a bougie?

Difficult airway leading to cricothyroidotomy Paediatric Difficult Airway Simulation

More airway learning material Optimus Bonus

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Please download our Facilitator and Learner guides


  • Robyn is an Advanced Trainee in Emergency Medicine and Paediatric Emergency Medicine in Sydney, Australia. She has a passion for medical education and improving paediatric critical care standards. When not at work she can be seen spending her time with her partner and her dog Marley exploring the great outdoors and chilling at the beach.


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