no apologies: intubation of the shocked patient
TRANSCRIPT
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
Image from Lifeinthefastlane.com
PHYSIOLOGY OF INTUBATION
Pre-inductionInductionApneaIntubation stimulusPost-intubationST
AG
ES
Image from Lifeinthefastlane.com
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
Image from Lifeinthefastlane.com
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
Image from Lifeinthefastlane.com
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