Pediatric & Neonatal Rapid Sequence Intubation: A High-Yield Clinical Quick-Reference

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Cognitive Aid & Pharmacology Reference

Pediatric & Neonatal Rapid Sequence Intubation

High-Yield Clinical Quick-Reference based on The Harriet Lane Handbook, 24th Edition.

The Four Phases of RSI

The Four Phases of RSI

• Phase 1: Preparation — Equipment sizing & baseline parameters.
• Phase 2: Adjuncts — Pre-treatment to mitigate physiologic responses.
• Phase 3: Induction — Sedation and amnesia.
• Phase 4: Paralysis — Neuromuscular blockade.

Follow this exact sequence to minimize patient stress, blunt intracranial responses, and secure the airway safely.

• Adjuncts (Blunting Reflexes): If indicated, give BEFORE induction and NMB.
• Induction (Sedation & Amnesia): Administer rapidly to achieve unconsciousness.
• Paralysis (Neuromuscular Blockade): Administer immediately following sedative.

Equipment Sizing by Age/Weight

Equipment Sizing

Equipment	Premie (1-3 kg)	Newborn (2-4 kg)	1 yr (10 kg)	4-6 yr (20-25 kg)	>16 yr (>50 kg)
Blade	MIL 0	MIL 0	MIL 1, MAC 2	MIL 2, MAC 2	MIL 2, MAC 3
ETT Size	2.5-3.0	3.0-3.5	4.0	5.5-6.0	7.0-8.0
LMA Size	1	1	2	2.5	4

Click on the “i” for more information!

Laryngoscope blade size (Additional Information)

Age	Type	Number
Premature <1000g	Miller	00
Premature 1000-2000 g	Miller	00 or 0
Premature 2000-3000 g	Miller	0 or 1
Neonate	Miller	0 or 1
1 – 6 months	Miller	0
6 – 12 months	Miller	1
1 – 2 years	Miller	1 – 2
3 – 4 years	Miller or Macintosh	2
5 – 6 years	Miller or Macintosh	2

Phase 1: RSI Adjuncts (Pre-Medication) — Atropine

Phase 1: RSI Adjuncts (Pre-Medication) — Atropine

• Benefit: Prevents bradycardia associated with laryngoscope insertion; decreases oral secretions.
• Indication: Bradycardia in any patient; infants <1 year; children 1-5 yrs receiving succinylcholine.
• Dosing: Varies by weight baseline. 0.02 mg/kg IV/IO/IM (max. 0.5 mg).
• Side Effects: Tachycardia.

App: Atropine — Intermittent IV – 1mg/mL Solution

⚠ Lethal dose (10mg) ⚠

Dose	0.04mg
Interval	10-15min

Dilution

Remove from vial	1mL
Dilute the dose in mL with NS or D5W	19mL
Final concentration after dilution	0.05mg/mL
Dose after dilution	0.8mL
Infusion rate	1min

Maximum dose

Maximum cumulative dose	0.08mg
Maximum cumulative dose	1.6mL

Phase 1: RSI Adjuncts (Pre-Medication) — Lidocaine

Phase 1: RSI Adjuncts (Pre-Medication) — Lidocaine

• Benefit: Blunts rise in ICP associated with laryngoscopy.
• Indication: Head trauma.
• Dosing: Varies by weight baseline. 1 mg/kg IV/IO (max. 100 mg).
• Side Effects: Hypotension risk in shock.

App: Lidocaine — Intermittent IV – 5mg/mL – 0.5%

Dose	2mg
Interval	10/10min
Dose	0.4mL

Dilution

Dilute the dose in mL with D5W, D10W, NS	1.6mL
Final concentration after dilution	1mg/mL
Total volume to be administered	2mL
Infusion rate	5min

Maximum dose

Maximum daily dose

10mg

App input options: Intermittent IV; 5mg/mL – 0.5%, 10mg/mL – 1%, 20mg/mL – 2%; No vasoconstrictor; Neurological patients. Suggested Loading dose: 0.5 to 1 mg/kg/day.

Note: initial bolus dose: intravenous dose of 0.5 to 1 mg/kg.

Phase 2: Induction Agents (Hemodynamic Profiles) — Fentanyl

Phase 2: Induction Agents (Hemodynamic Profiles) — Fentanyl

Analgesic / Sedative

• Benefit: Minimal cardiovascular effect.
• Indication: Shock.
• Dosing: 1-5 mcg/kg slow IV/IM.
• Side Effects: Respiratory depression, chest wall rigidity with rapid push.

App: Fentanyl — Intermittent IV – 50mcg/mL

Dose	2mcg
Interval	AMD

Dilution

Remove from vial	0.5mL
Dilute with NS	12mL
Final concentration after dilution	2mcg/mL
Dose after dilution	1mL
Infusion rate	15-30 min

App input: Weight (kg) 2; Desired dose (mcg/kg/dose) 1. Suggested dose: 0.5 to 50 mcg/kg/dose.

Note: this presentation includes all the presentations on the market (including 0.0785 mg/mL). For analgesia, a dose of 0.5 to 3 mcg/kg/dose is recommended, for anesthesia a dose range of 5 to 50 mcg/kg/dose is recommended and for sedation 0.5 to 4 mcg/kg/dose. The interval of use is generally 2 to 4 hours. The final concentration should be up to 10 mcg/mL and the one used for the calculation was 2 mcg/mL.

How to Use the App for Intubation Medications

Two ways to select intubation medications

Two ways to do: More practical: select “intubation” on the input screen and select the medications for the procedure; Or go to “medicines” and take one medications at a time.

Home menu options: Venous hydration; Continuous medication; Medicines; Intubation; Other calculations and scores; Procedures.

Intubation — Sedonalgesia

Fentanyl — Fentanyl 50mcg/mL. Suggested dose: 0.5 to 4 mcg/kg/dose.

Other medicines: Fentanyl (selected), Remifentanil, Morphine, Midazolam, Thiopental, Propofol, Muscle blockers.

Results screen

Pre-Medication — Atropine 0.1mg/mL Solution: Remove 0.5mL from the ampoule and dilute with 1mL of NS or D5W and administer the 0.61mL.

Sedonalgesia — Fentanyl 50mcg/mL: Remove 0.5 mL from the ampoule and dilute with 12 mL of NS and administer the 1mL.

Additional information: Bibliographical references.

Please note: the information presented in this…

Phase 2: Induction Agents (Short-Acting Profile) — Midazolam

Phase 2: Induction Agents (Short-Acting Profile) — Midazolam

Short-Acting Benzodiazepine

• Benefit: Rapid and predictable onset of action, short recovery time, causes amnesia.
• Dosing: 0.1-0.2 mg/kg IV.
• Side Effects: Results in mild depression of hypoxic ventilatory drive.

• Onset: 1-3 mins (IV)
• Onset: 5-10 mins (IM/IN)

App input options: IV bolus or IM; Nasal or SL; Oral. Solutions: 1mg/mL Solution, 5mg/mL Solution. Weight (kg) 2; Desired dose (mg/kg) 0.1. Suggested dose: 0.05 to 0.15 mg/kg.

App: Midazolam — IV bolus or IM – 1mg/mL Solution

Dose	0.2mg
Interval	2 – 4h
Dose	0.2mL

Dilution

Dilute the dose in mL with NS, D5W	0.2mL
Final concentration after dilution	0.5mg/mL
Dose after dilution	0.2mL
Infusion rate	10 min

Phase 3: Neuromuscular Blockade (Depolarizing)

Phase 3: Neuromuscular Blockade (Depolarizing)

App view — Intubation / Muscle blockers

Succinylcholine

Available formulations:

• 100mg Powder
• 500mg Powder
• 10mg/mL Solution
• 20mg/ml Solution
• 40mg/mL Solution
• 50mg/mL Solution
• 100mg/mL Solution

Selected: Succinylcholine 100mg Powder

Suggested dose: 1 to 2 mg/kg

Other medicines: Rocuronio, Vecuronium, Pancuronium, Succinylcholine (selected)

Contraindications

• Neuromuscular disease / Myopathies
• Spinal cord injury
• Crush injury
• Burns
• Renal insufficiency

Succinylcholine — Depolarizing Agent

Benefit: Rapid, profound paralysis (Onset 30-60 sec).

Dosing:

• ≤2 years: 2 mg/kg IV
• >2 years: 1 mg/kg IV

Rocuronium Bromide Injection

Rocuronium Bromide Injection

NDC 71839-141-01

Rocuronium Bromide Injection — 50 mg/5 mL (10 mg/mL). Intravenous Use Only. WARNING: Paralyzing Agent. 5 mL Multiple-dose Vial.

Benefit: Minimal cardiovascular effect; rapid onset at RSI doses.

Indication: Caution in patients with a difficult airway.

Side Effects: Prolonged paralysis if airway fails and reversal is unavailable.

Reversal: Fully reversible with Sugammadex.

Precise RSI Dosing: 1.2 mg/kg IV/IM/IO

Rocuronio and Vecuronium App View

Neofast — Intubation

Rocuronio

Selected: Rocuronio 10mg/mL Solution

Suggested dose: 0.5 to 1.2 mg/kg

Vecuronium

Available formulations:

• 4mg Powder
• 5mg Powder
• 10mg Powder
• 20mg Powder

Selected: Vecuronium 4mg Powder

Suggested dose: 0.03 to 0.15 mg/kg

Other medicines:

• Rocuronio (selected)
• Vecuronium (selected)
• Pancuronium
• Succinylcholine

Phase 3: Neuromuscular Blockade (Non-Depolarizing Alternative)

Phase 3: Neuromuscular Blockade (Non-Depolarizing Alternative)

Vecuronium — Non-depolarizing Agent

Benefit: Minimal cardiovascular effect, reversible with sugammadex.

Indication: Caution in patients with difficult airway.

Dosing: 0.1 mg/kg IV.

Comparison Callout

Limitations vs. Rocuronium:

• Longer time to paralysis than rocuronium.
• Prolonged duration in hepatic failure.

Neonatal Context: Special Considerations

Weight Baselines

• Extremely Low Birth Weight (ELBW) = <1000g
• Very Low Birth Weight (VLBW) = <1500g
• Low Birth Weight (LBW) = <2500g

Resuscitation Energy — Dextrose administration during active resuscitation:

• Newborn: 5-10 mL/kg D10W
• Monitor carefully for rebound hypoglycemia.

ETT Meds (NAVEL)

• N – Naloxone
• A – Atropine
• V – Vasopressin
• E – Epinephrine
• L – Lidocaine

Dilute medications to 5 mL with NS, follow with positive-pressure ventilation.

Master Synthesis: RSI Pharmacologic Cheat Sheet

Master Synthesis: RSI Pharmacologic Cheat Sheet

Phase	Medication	Dose	Primary Benefit	Key Caution
Adjunct	Atropine	Varies	Prevents bradycardia	Tachycardia
Adjunct	Lidocaine	1 mg/kg	Blunts ICP rise	Hypotension
Induction	Fentanyl	1-5 mcg/kg	Minimal CV effect	Chest wall rigidity
Induction	Ketamine	1-2 mg/kg	Bronchodilation	Increases HR
Induction	Midazolam	0.1-0.2 mg/kg	Amnesia / Rapid onset	Depresses vent drive
Paralytic	Succinylcholine	1-2 mg/kg	Rapid onset (30s)	Hyperkalemia / Myopathy
Paralytic	Rocuronium	1.2 mg/kg	Reversible w/ Sugammadex	Difficult airway risk
Paralytic	Vecuronium	0.1 mg/kg	Minimal CV effect	Prolonged in hepatic failure

neofast — Get it on Google Play / Download on the App Store

Phase 1: Adjuncts

Phase 1: Adjuncts

Medication	Benefit	Indication	Dosing	Side Effects
Atropine	Prevents bradycardia associated with laryngoscope insertion; decreases oral secretions.	Bradycardia in any patient; infants <1 year; children 1–5 years receiving succinylcholine; children >5 years receiving a second dose of succinylcholine.	[Refer to institutional protocol]	Tachycardia.
Lidocaine	Blunts rise in Intracranial Pressure (ICP) associated with laryngoscopy.	Head trauma.	[Refer to institutional protocol]	[Refer to institutional protocol]

Table 1.2 Rapid Sequence Intubation Medications

Table 1.2 — Rapid Sequence Intubation Medications

Intubation technique notes: (e) If able to visualize the vocal cords, place the ETT to the right of the blade and advance until the cuff is past the vocal cords. (f) Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients, but can be considered along with readjustment of laryngoscope.

1. Induction Agents

Medication	Benefit	Indication	Dosing	Side Effects
Etomidate (sedative)	Minimal cardiovascular side effects, minimally decreases ICP	Multitrauma patient at risk for increased ICP and hypotension. Caution in patients at risk for adrenal suppression (septic shock)	0.3 mg/kg IV/IO (max. 20 mg)	Suppresses adrenal corticosteroid synthesis, vomiting, myoclonus; lowers seizure threshold
Fentanyl (analgesic, sedative)	Minimal cardiovascular effect	Shock	1–5 mcg/kg slow IV/IM push (max. 100 mcg)	Chest wall rigidity, bradycardia, respiratory depression
Ketamine (sedative, analgesic)	Catecholamine release causes bronchodilation, abates bradycardia associated with laryngoscope insertion, increases HR and SVR, produces a “dissociative amnesia”	Status asthmaticus, shock and hypotensive patients. Caution in patients at risk for elevated ICP or with glaucoma history	1–2 mg/kg IV/IO (max. 150 mg); 4–6 mg/kg IM	Vomiting, laryngospasm, hypersalivation, emergence reactions (hallucinations)
Midazolam (sedative, amnestic, anxiolytic)	Minimal cardiovascular effect	Mild shock	0.05–0.1 mg/kg IV/IM/IO (max. single dose 6–10 mg depending on age, see Formulary)	Dose-dependent respiratory depression, hypotension
Propofol (sedative)	Ultra-short acting	Avoid in shock or patients who require maintenance of CPP	2 mg/kg IV	Hypotension, myocardial depression, metabolic acidosis; may cause paradoxical hypertension in children

2. Neuromuscular Blockade

Medication	Benefit	Indication	Dosing	Side Effects
Succinylcholine (depolarizing)	Rapid-onset, short-acting neuromuscular blockade agent, reversible with acetylcholinesterase inhibitor	Role limited due to adverse events. Contraindicated in neuromuscular disease, myopathies, spinal cord injury, crush injury, burns, renal insufficiency	IV: ≤2 years: 2 mg/kg; >2 years: 1 mg/kg (30–60-sec onset, 4–6-min duration). IM: 3–4 mg/kg (3–4-min onset, 10–30-min duration). Max. dose: 150 mg/dose IM	Hyperkalemia; trigger of malignant hyperthermia; masseter spasm, bradycardia; muscle fasciculations; increased intracranial, intraocular, and intragastric pressure
Rocuronium (nondepolarizing)	Minimal cardiovascular effect, reversible with sugammadex	Caution in patients with difficult airway	1.2 mg/kg IV/IM/IO (30–90-sec onset, 30–45-min duration). Max. dose: 100 mg	Prolonged duration in hepatic failure
Vecuronium (nondepolarizing)	Minimal cardiovascular effect, reversible with sugammadex	Caution in patients with difficult airway	0.15–0.2 mg/kg IV/IO (1–3-min onset, 30–40-min duration). Max. dose: 10 mg	Prolonged duration in hepatic failure, longer time to paralysis than rocuronium

3. Adjuncts (If indicated, should be given before induction and NMB medications)

Medication	Benefit	Indication	Dosing	Side Effects
Atropine	Prevents bradycardia associated with laryngoscope insertion, decrease oral secretions	Bradycardia in any patient, infants <1 year, children 1–5 years receiving succinylcholine, children >5 years receiving a second dose of succinylcholine	0.02 mg/kg IV/IO/IM (max. 0.5 mg)	Tachycardia, pupil dilation
Glycopyrrolate	Decreases oral secretions, prevent bradycardia; may cause less tachycardia than atropine, preserves pupillary exam in trauma	Hypersalivation	0.004–0.01 mg/kg IV/IM/IO (max. 0.1 mg)	Tachycardia
Lidocaine	Blunt rise in ICP associated with laryngoscopy	Elevated ICP, shock, arrhythmia, and status asthmaticus	1 mg/kg IV/IO (max. 100 mg)	Myocardial depression, altered mental status, seizures, muscle twitching

CPP, Cerebral perfusion pressure; HR, heart rate; ICP, intracranial pressure; IM, intramuscular; IO, intraosseous; IV, intravenous; mcg, microgram; NMB, neuromuscular blockade; SVR, systemic vascular resistance.

Phase 2: Induction Agents

Phase 2: Induction

Fentanyl

Analgesic, Sedative

• Shock (Minimal cardiovascular effect)
• 1–5 mcg/kg slow IV/IM

Ketamine

Sedative, Analgesic

• Benefit: Catecholamine release causes bronchodilation, abates bradycardia, increases HR.
• Indication: Asthma, Shock

Midazolam

Sedative, Amnestic

• Check for hypotensive risks. Ideal for procedural sedation. (Onset 1-3 min)

Propofol

Sedative, Hypnotic

• Monitor for hypotension, respiratory depression, cardiac failure.

Phase 3: Neuromuscular Blockade

Phase 3: Neuromuscular Blockade

Succinylcholine (Depolarizing)

Dose: ≤2 years: 2 mg/kg IV | >2 years: 1 mg/kg IV

Benefit: Ultra-rapid onset (30-60 sec).

CONTRAINDICATED in neuromuscular disease, myopathies, spinal cord injury, crush injury, burns, renal insufficiency.

Vecuronium (Nondepolarizing)

Benefit: Minimal cardiovascular effect; reversible with sugammadex.

Indication: Caution in patients with difficult airways.

Side Effects: Prolonged duration in hepatic failure; longer time to paralysis than rocuronium.

Rocuronium: The Agent of Choice

Rocuronium: The Agent of Choice

Gold Standard

Class: Nondepolarizing NMB  |  Route: IV / IM / IO

1.2 mg/kg

• Hemodynamically Stable. Minimal cardiovascular effect.
• Indication. Caution in patients with a difficult airway.
• Reversible. Fully reversible with Sugammadex, avoiding the contraindication risks of Succinylcholine.

Neonatal Airway Algorithm

Neonatal Airway Algorithm

1. Apnea or gasping? HR < 100 bpm? — YES
2. Initiate PPV. Apply Pulse Oximeter. Consider cardiac monitor. — HR still < 60 bpm?
3. Consider ETT or Laryngeal Mask. Chest compressions. Coordinate with PPV (100% Oxygen). UVC. — HR remains < 60 bpm?
4. IV Epinephrine every 3–5 minutes. Consider hypovolemia/pneumothorax.

Neonatal Target Metrics

Neonatal Target Metrics

Target Oxygen Saturation Curve

Minutes	SpO2%
1	60%–65%
3	70%–75%
5	80%–85%
10	85%–95%

Initial Oxygen Concentration (PPV)

• ≥ 35 weeks’ Gestational Age: 21% Oxygen
• < 35 weeks’ Gestational Age: 21%–30% Oxygen

Rescue Pathway: Opioid Reversal

Rescue Pathway: Opioid Reversal

Indications

• Shallow respirations or RR < 8 breaths/min
• Pinpoint pupils
• Unresponsive to physical stimulation

NALOXONE (Narcan)

Dose: 1-2 mcg/kg/dose IV

Administration: Give slowly over 2 minutes.

Titration: Titrate to effect up to a total dose of 10 mcg/kg. If no response, evaluate other causes.

Action shorter than most opioids. Monitor closely; another dose may be required within 30 minutes.