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Author Topic: Emergent tracheal intubation of the critically ill  (Read 2918 times)

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gassy

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Emergent tracheal intubation of the critically ill
« on: November 23, 2007, 04:13:27 AM »
For a patient who is septic or otherwise acidotic and hypovolemic with tachypnea (respiratory compensation for metabolic acidemia) and obtundation, tracheal intubation may be required to protect the airway, prevent respiratory failure or facilitate sedation/immobilization for procedures.  On the other hand, sedation/paralysis and/or loss of negative intrathoracic pressure can lead to hemodynamic collapse due to loss of sympathetic tone and decreased venous return.  Anyone have a strategy for coping with this dilemma?

Related question:  Anyone have a reference discussing/quantitating the decrement in endogenous catecholamine secretion associated with tracheal intubation of a patient who is dependent on sympathetic drive?
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jafo1964

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Re: Emergent tracheal intubation of the critically ill
« Reply #1 on: November 25, 2007, 08:14:04 PM »
An obtunded patient may not require anything at all for intubation.  All comatosed trauma patients are just intubated. Maybe a few squirts of laryngotracheal lignocaine spray.

Disoriented, unco-operative, Haemodynamically unstable patient - most trauma patients with head injury fall into this category

These patients are potential full stomach and require RSI with cricoid pressure
Intubation should be fast, smooth and safe - oral route i guess meets all these requirements

Good IV line with fluids flowing, emergency drugs and airway equipment, vasopressors diluted and ready,monitors
Pre-oxygenate - Bag mask ventilation if necessary
Induction choices - Fentanyl  2 mcg/kg + Midazolam 1 -2 mg
                           Ketamine  titrated 1- 2 mg/kg
                           Eomidate titrated

Most of these do not produce haemodynamic instability. Even if a little drop occurs can be manged with fluid boluses + vasopressors.
Remember in trauma patients ABC - airway & breathing has to be set right before circulatory hypotension is corrected

Relaxant - Low dose Suxa with RSI 0.5 mg /kg - recommended in unstable trauma patients (Ref: Miller 6th ed muscle relaxants).
Rocuronium may be an alternative


I think your worry although genuine, is not unmanageable. It is exactly the group of patients as described by you who go on ventilators. Sedation, Paralysis and IPPV is needed to salvage them as also to provide anaesthesia for trauma patients with life threatening emergencies. Loss of sympathetic tone should be anticipated and minimized and when it occurs can definitely be managed

regards
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