no apologies: intubation of the shocked patient

Chris Nickson FCICM FACEM Intensivist, The Alfred ICU

NO APOLOGIES

INTUBATION OF THE SHOCKED PATIENT

http://litfl.org/shock-tube

NO CONFLICTS OF INTEREST

OB

JEC

TIVE

S1 Know what kills2 Make a (good) plan3 Get the drugs right

NO APOLOGIESWhat’s with the title?

SUXTUBE

APOLOGY

Image from Lifeinthefastlane.com

OBJECTIVE #1KNOW WHAT KILLS

HYPOTENSION +

INTUBATION

= DEATHPhoto by Tim Norris, https://www.flickr.com/photos/tim_norris/2538415572

Schwartz et al, 1990 PMID: 7856895

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PHYSIOLOGY OF INTUBATION

Pre-inductionInductionApneaIntubation stimulusPost-intubationST

AG

ES

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CAUSES OF HYPOTENSION

Resuscitation inadequateAcidaemiaPositive pressure (PPV)Induction agentsDisease

HYP

OTE

NSI

ON

ALL SHOCK STATES ARE NOT

CREATED EQUAL

HEART-BRAIN AXIS

VentilationAcidaemiaPressuresOxygenationRegurgitation/ FluidsDA

NG

ERS

Modified from Rich Levitan (@airwaycam)

Image from Lifeinthefastlane.com

OBJECTIVE #2MAKE A (GOOD) PLAN

Secure a patent and protected airway without physiological compromise or complications

as rapidly as possible

Hierarchy of Emergency Intubation Needs(Weingart & Nickson)

Dunford et al, 2003 PMID: 14634593.

FIRST PASS SUCCESSNO HYPOXIA

NO HYPOTENSION

You MUST always perform classic RSI!

DON’T RSI, MODIFY

DON’T RSI, MODIFYHow about

Resuscitation

Sequence Intubation?

Richard Levitan

IT IS NOT ALL ABOUT INDUCTION AGENTS

VentilationAcidaemiaPressuresOxygenationRegurgitation/ FluidsDA

NG

ERS

Modified from Rich Levitan (@airwaycam)

Pre-inductionInductionApneaIntubation stimulusPost-intubationST

AG

ES

RESUSCITATE BEFORE YOU INTUBATE

START INOPRESSORS PERIPHERALLY

AVOID APNOEA IN SEVERE ACIDAEMIA

VENTILATE GENTLY

WATCH CAREFULLYACT FAST

MAKE IT HAPPEN

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OBJECTIVE #3GET DRUGS RIGHT

Sunday December 7th, 1941

ALL INDUCTION DRUGS

CAN CAUSE HYPOTENSION

DOSING IS MORE IMPORTANT

THAN THE DRUG

http://en.wikipedia.org/wiki/Ketamine

http://en.wikipedia.org/wiki/Ketamine

Image courtesy of pedemmorsels.com

Shafer, 2004 PMID: 15329579.

Remember, Shock is

an anaestheti

c!

Rick Dutton

ETOMIDATEPROPOFOL

THIOPENTONEMIDAZOLAM &

FENTANYLIND

UC

TIO

N

ETOMIDATEPROPOFOL

THIOPENTONEMIDAZOLAM &

FENTANYLIND

UC

TIO

N

ETOMIDATEPROPOFOL

THIOPENTONEMIDAZOLAM &

FENTANYLIND

UC

TIO

N

ETOMIDATEPROPOFOL

THIOPENTONEMIDAZOLAM & FENTANYLIND

UC

TIO

N

ROCURONIUM OR SUXAMETHONIUM?

Image courtesy of Cliff Reid

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SUMMARY

Hypotension = deathShock is an anaestheticFix the VAPORModify your RSIThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU

MM

ARY

http://lifeinthefastlane.com/2009/04/laws-for-the-navigation-of-life/

The 22nd of Peter Safar’s Laws for the Navigation of Life

It is up to us to save the

world!

http://litfl.org/shock-tube