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 [cite source='pubmed']23511147[/cite]
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
Preoxygenation
Ap Ox and high-flow fiO2 for the full 3 minutes or longer
ETCO2
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
Pretreatment
Control the BP BEFORE the intubation with nicardipine or clevidipine
Lidocaine
While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.[cite source='pubmed']11696494[/cite] 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. [cite source='pubmed']22633717[/cite] This one shows the hypotension potential. [cite source='pubmed']25237632[/cite]
Local is more effective than IV. [cite source='pubmed']10861151[/cite]
Lidocaine References [cite source='pubmed']11696494[/cite], [cite source='pubmed']17358099[/cite], [cite source='pubmed']23683444[/cite], [cite source='pubmed']7772359[/cite],
Fentanyl
Dose 5 mcg/kg [cite source='pubmed']6318605[/cite], [cite source='pubmed']7032347[/cite]
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
Remifentanil can also be used, but I don't have so I can't speak about it
Esmolol
Dose 1.5-2 mg/kg ~ 3min beforehand
Combo of Esmolol and Fentanyl [cite source='pubmed']1363221[/cite]
[cite source='pubmed']7788827[/cite]
[cite source='pubmed']9084524[/cite],[cite source='pubmed']1672488[/cite]
Nicardipine
Dose 20 mcg/kg (average 1.4 mg)
[cite source='pubmed']21696933[/cite] and [cite source='pubmed']10553821[/cite] and Review Article (16978041)
Other Group's Recs
At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead
Osmotic Therapy
Probably a good time to give a dose of hypertonic saline
Induction Agents
Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.
Muscle Relaxants
Rocuronium or Succinylcholine at full dose
Positioning
Head of Bed at least to 30, preferably to 45
Post-Intubation Sedation
Propofol and Fentanyl
Post-Intubation Ventilation
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
Other Situations
Basilar Stroke and Stuttering Stroke-lower bp=screwed
Review Article
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
Additional New Information
- Podcast 84 – The Post-Intubation Package(Opens in a new browser tab)
- EMCrit 173 – LaMW – Oxygenation Kills Part I
- EMCrit 174 – LaMW – Oxygenation Kills Part II
- Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills
- EMCrit 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis
More on EMCrit
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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- ODR 013 – Should, Must, & Won't - November 25, 2023
- EMCrit Shadowboxing Case 6 – A Respiratory Case along with Extra Commentary from Mae West - November 23, 2023
Alfentanyl 20-30mcg/kg 30 seconds prior.
Remi on infusion as it wears off too quickly to time it well with laryngoscopy.
Lower dose of lipophilics and higher dose of neuromuscular blockers for peripherally shut down patients.
Regards,
Jamie
ED trainee
Australia
Ahh nice call on the alfent, but I don’t have that either. Remi with induction agent/paralytic should be timed directly to the laryngoscopy’s reflex surge. Not sure of the relevance of the shut down stuff–see the hemodynamically unstable lecture for that stuff.
Great post – as always ONS – Optic Nerve Sheath is a great tool to identify patients at risk for critical ICP. Especially if you take in account young patients who have a normal looking CCT. As they have no reserve space for swelling they will deteriotate fast. If you have ever changed a tube or performed a tracheostomy while the patient is under ICP monitoring then you see how fast the numbers can raise up. So the techniques described in the podcast can also be used for elective procedures on a NICU. In Germany we use urapidil as our… Read more »
fantastic!
What about pretreatment with fentanyl and induction with ketamine? These older articles suggest this combination disturb HR and MAP the least. 1. Katz et al. Hemodynamic stability and patient satisfaction after anesthetic induction with thiopental sodium, ketamine, thiopental-fentanyl, and ketamine-fentanyl. J Clin Anesth 1993, Mar;5:134-40. 2. Katz et al. Haemodynamic stability and ketamine-alfentanil anaesthetic induction. Br J Anaesth 1998, Nov;81(5):702-6. A good review article from 1996: Kovac AL. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. J Clin Anesth 1996, Feb;8(1):63-79. But practically, from a semi-elective intubation standpoint, you could have infusions of propofol, fentanyl, labetalol / esmolol already… Read more »
most EDs and ICUs lack syringe pumps, they use bag roller pumps. It is much safer on these pumps to draw up sticks of medication
You didn’t say anything about setting up an arterial line, something I consider almost necessary in order to control blood pressure in these situations. Did I miss something, or do you think non invasive blood pressure is good enough?
Thanks for the excellent podcast
Wilhelm Wallquist
Anesthesiologist and critical care physician
Sweden
its a great point! All these patients get a-lines in my place, but we usually wait until after. It would be nice to have before intubating, though I think the non-invasive BP is fine for the elevated BP situations. I find they fail in hypotension. You just need to make sure the rep. time is reasonable.
Always interesting, Scott. A couple of thoughts. First of all, fentanyl (or any other opiate) is almost always a good choice. I would caution, however, that CO2 can rise if the pt is not being ventilated adequately (why is the patient being intubated in the first place?) which is not good for the brain. Also, nicardipine is ok, but has been shown to have a higher incidence of hypotension compared to other agents (esmolol?) in part due to its relatively longer half life, making it a little more difficult to rapidly titrate. (Yes, a pre-induction a line would be key).… Read more »
I can’t help but cringe a bit at your suggestion for “push dose nicardipine,” especially as a remedy in case the provider “screws up” a push dose pressor such as epinephrine. Having physicians mix up these push dose vasoactive agents at the bedside is just asking for a disastrous error. Unfortunately, epinephrine is one of the only drugs I’m aware of which has its concentration still expressed in ratio strength (e.g. 1:10,000 or 1:1000) instead of mass concentration. There’s loads of documentation in the literature related to dosing errors with epinephrine, and we know that physicians don’t do particularly well… Read more »
Meghan, I think I understand your viewpoint. Unfortunately it is this viewpoint that may be contributing to the lack of experience on the part of physicians in the ED and ICUs on mixing up these drugs. Have you worked in an OR as part of your work experience? If not, it may be worth hanging out with the anesthesiologists for some of their high risk cases (or even the routine ones). I think you will find a very different approach to push-dose medications and to how those medications are mixed up. I will also refer you to the blog of… Read more »
At the beginning of the podcast, you make a comment about Lidocaine and Fentanyl in TBI and “killing those patients”. We frequently use both of these medications (and as an ICU/Flight RN we are at the mercy of our medical control physician) in PAI for head injury patients. As our protocol committee chair, journal nerd, and FNP student, I have not seen any literature that puts our patients at higher risk for untoward outcomes when used properly. Is there evidence that these meds are potentially harmful? The only thing that I have found is that opioids may increase or contribute… Read more »
Chris, you lost me. the comment was regarding giving these meds to hypotensive patients–that is indeed a very effective way to kill these patients.
Ok, that’s what I thought but wasn’t sure. Thank you for the verification.
Chris A
great podcast. curious why you make it a point though to mention “no peep unless necessary, but if necessary its safe to use”? I think what some people interpret as “low peep” or “high peep” varies drastically. At my shop, the anesthesiologists ROUTINELY have people on zero peep. So, if one of them were reading this page, I fear him/her would do what you say and do a beautiful intubation, put the patient on zero peep, and then have the icu pay the price a couple hours later. I, on the other hand, routinely start standard, run of the mill,… Read more »
in poorly compliant lungs, PEEP will not affect the ICP and is beneficial for the reasons you have mentioned. In patients with normal lungs, there is a PEEP level that will increase ICP and potentially limit venous return and CO-worsening CPP. The rule for these intubations should be the same as in all others-use whatever PEEP you need to get the best cardiopulmonary situation. I have sent you a powerpoint by email.
s
The review article you have posted sites the wrong dosing of esmolol…they recommend a dose of 1-2mcg/kg for pretreatment which is a thousand fold difference from the correct 1-2mg/kg dose.
Also, looking critically at most of the literate here, there is usually a drop in blood pressure below baseline following successful intubation after pretreatment. However, most of the studies done were with thiopental. Which do you think is worse; hypotension or hypertension for these patients and do you ever drop the dose of fentanyl/esmolol or just use a single agent to prevent RSRL?
Thanks,
Adam Bloom
Adam, Not sure if you are going by the show notes or have listened to the episode. I don’t recommend esmolol at all as a prophylactic agent. I just use the fentanyl unless blood pressure already through the roof. Just as you say, many of these pts drop their BP in the post-induction.
Ahh, just listened to it again and caught that part. Thank you very much for the quick reply.
What’s the timing of the fentanyl here? On induction(which seems a bit early, given onset), or pre-treatment/ dsi?
Seems to make pt apnoeic even at 3mcg/kg….
Pretreatment medications are given 3-5 minutes prior to induction. Think we addressed the apnea issue in the podcast.
You did indeed, thanks. Have you discussed the tranlslation of the neuroprotective approach to the head injured patient?