EM Quick Hits Video on Neuroprotective Intubation with Katie Lin
3 Pearls for neuroprotective intubation
Extra caution is required when intubating patients with neurocritical conditions.
- Consider airway management prior to imaging or transport.
- These conditions can progress quickly; low threshold to intubate
- Consider rapid airway control when: active vomiting, agitated, rapidly decreasing GCS, apneic spells
- Include a 10 second neuro exam pre-intubation if possible.
- 2 questions our stroke/neurosurgery/ICU colleagues want to know from us:
- Are they herniating or severely disabled?
- Determines the urgency of intervention
- Is the brain still salvageable?
- Determine if an intervention will make a difference in the outcome
- Are they herniating or severely disabled?
- 3 steps to the neuro exam:
- Step 1: GCS – What is the LOC and is it dropping?
- Step 2: Eyes – Are the pupils equal and reactive? Are they disconjugate or deviated? Are the corneal reflexes in tact?
- Step 3: Lateralizing motor response: Purposeful movement equally bilaterally? Is there asymmetry or posturing present?
- 2 questions our stroke/neurosurgery/ICU colleagues want to know from us:
- Keep it simple to avoid hypotension and hypoxia
- Choose the tools and approach you are most experienced with; usually this will be an RSI
- Here is an example approach:
- Preoxygenate with a non-rebreather over highflow nasal cannula
- Pretreat with an antiemetic if vomiting, fentanyl if hypertensive, and a vasopressor (norepinephrine or phenylephrine) if hypotensive
- Prepare equipment, yourself and team for A, B and C plans including a well-defined oxygenation threshold and designate someone to call this out; consider a target of 90%
- Position the patient with head of bed 15-30 degrees to mitigate ICP effect even if in spinal precautions
- Induce the patient – Ketamine 1.5 mg/kg ~100-150 mg
- Paralysis
- Succinylcholine
- Advantage: wears off quickly to resume neurologic monitoring
- Caution: There may be a transient increase in ICP during the defasciculation phase but there is no evidence that this has any clinically significant effect of neurological outcome
- Rocuronium advantages
- Nondepolarizing so there is no theoretical increase in ICP
- There are few contraindications
- Keeps the patient imobile i.e. for imaging and transfer
- Succinylcholine
- Post-intubation sedation
- Propofol and fentanyl infusions if normo- or hypertensive
- Ketamine if hypotensive
- Neuroprotective ventilation targets
- RR 16
- TV 8 cc/kg
- FIO2 100%
- PEEP 5 mmHg
- PaCO2 35-40
- O2 sats >94%
- If time, some ‘nice to haves’:
- Fentanyl 3 mcg/kg (~200 mcg) 3 minutes prior to intubation if normo- or hypotensive.
- Lidocaine spray to the cords to prevent increased ICP with laryngeal stimulation.
Bottom line =>
- Consider rapid airway control prior to imaging or transport with a lower threshold if vomiting, agitation, dropping GCS, or dysregulated breathing with apneic spells
- Include a 10 second neuro exam if possible focusing on GCS, eyes, and lateralizing findings
- Keep your approach simple using tools you are familiar with; focus on avoidance of hypotension and hypoxia
In each EM Quick Hits Video, our team hand picks an EM Quick Hits podcast segment and curates a video to enhance you multimodal learning.
Our EM Quick Hits Video team is: Lara Murphy and Yajur Iyengar and Jonathan Whittall
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