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.

  1. 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
  2. Include a 10 second neuro exam pre-intubation if  possible.
    • 2 questions our stroke/neurosurgery/ICU colleagues want to know from us:
      1. Are they herniating or severely disabled?
        • Determines the urgency of intervention
      2. Is the brain still salvageable?
        • Determine if an intervention will make a difference in the outcome
    • 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?
  3. 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:
      1. Preoxygenate with a non-rebreather over highflow nasal cannula
      2. Pretreat with an antiemetic if vomiting, fentanyl if hypertensive, and a vasopressor (norepinephrine or phenylephrine) if hypotensive
      3. 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%
      4. Position the patient with head of bed 15-30 degrees to mitigate ICP effect even if in spinal precautions
      5. Induce the patient – Ketamine 1.5 mg/kg ~100-150 mg
      6. 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
      7. Post-intubation sedation
        • Propofol and fentanyl infusions if normo- or hypertensive
        • Ketamine if hypotensive
      8.  Neuroprotective ventilation targets
        • RR 16
        • TV 8 cc/kg
        • FIO2 100%
        • PEEP 5 mmHg
        • PaCO2 35-40
        • O2 sats >94%
      9. If time, some ‘nice to haves’:
        1. Fentanyl 3 mcg/kg (~200 mcg) 3 minutes prior to intubation if normo- or hypotensive.
        2. Lidocaine spray to the cords to prevent increased ICP with laryngeal stimulation.

Bottom line =>

  1. Consider rapid airway control prior to imaging or transport with a lower threshold if vomiting, agitation, dropping GCS, or dysregulated breathing with apneic spells
  2. Include a 10 second neuro exam if possible focusing on GCS, eyes, and lateralizing findings
  3. Keep your approach simple using tools you are familiar with; focus on avoidance of hypotension and hypoxia

The Podcast: EM Quick Hits 55 – Induction Agents, Gabapentinoids, Neuroprotective Intubation, Approach to Paresthesias, Preventing Burnout

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