This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.
Who is this For?
Semi-elective intubations for patients with presumed or known elevated ICP
In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP (23511147)
The prototypical case requiring this treatment is a high-grade SAH prior to securing the aneurysm
This is the same way we would intubate an aortic dissection patient
Ap Ox and high-flow fiO2 for the full 3 minutes or longer
Put it on the BVM
Non-Pharmacologic Methods to Blunt Reflex Response
Limit time of laryngoscopy and atraumatic laryngoscopy
Leave the patient upright until the last possible moment, then intubate in 20 degrees head-up
No-touch intubation with video laryngoscopy by the best intubator
Control the BP BEFORE the intubation
While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.(11696494) Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. (22633717) This one shows the hypotension potential. (25237632)
Local is more effective than IV. (10861151)
All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.
Remifentanil can also be used, but I don’t have so I can’t speak about it
Dose 1.5-2 mg/kg ~ 3min beforehand
Dose 20 mcg/kg (average 1.4 mg)(21696933) and (10553821) and Review Article (16978041)
Other Group’s Recs
At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead
Probably a good time to give a dose of hypertonic saline
Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.
Rocuronium or Succinylcholine at full dose
Propofol and Fentanyl
Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use
Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas
Basilar Stroke and Stuttering Stroke-lower bp=screwed
Has anyone found a good one for ICP
Here is a great article for the high-risk vascular intubation
Rich Levitan’s Airway Course
Go here to get the scoop