The Airway Moratorium is Over!
In this podcast I talk about how not to kill the shocked/hypotensive patient in the peri-intubation. I gave this talk at SMACC 2013.
This lecture is part of the Laryngoscope as a Murder Weapon Series:
- Hemodynamic Kills
- Oxygenation Kills (for this one you need to be a CME Member or Invite Me for Grand Rounds)
- Ventilatory Kills
Best Review Article
Hypotension in the peri-intubation is bad and is a source of mortality
Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367) and (Heffner et al. J Crit Care 2012 Aug;27(4):417)
Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)
Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)
Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)
Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability
A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.
Cats did fine (Canad Anesth Soc J 1975;22(3):339). However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.
Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)
Ketamine in ICP (Emerg med australia 2006;18(1):37-44)
Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.
Anesth Analg. 2000 Jan;90(1):175-9.