no apologies: intubation of the shocked patient
TRANSCRIPT
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Chris Nickson FCICM FACEM Intensivist, The Alfred ICU
NO APOLOGIES
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INTUBATION OF THE SHOCKED PATIENT
http://litfl.org/shock-tube
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NO CONFLICTS OF INTEREST
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OB
JEC
TIVE
S1 Know what kills2 Make a (good) plan3 Get the drugs right
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NO APOLOGIESWhat’s with the title?
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SUXTUBE
APOLOGY
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Image from Lifeinthefastlane.com
OBJECTIVE #1KNOW WHAT KILLS
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HYPOTENSION +
INTUBATION
= DEATHPhoto by Tim Norris, https://www.flickr.com/photos/tim_norris/2538415572
Schwartz et al, 1990 PMID: 7856895
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Image from Lifeinthefastlane.com
PHYSIOLOGY OF INTUBATION
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Pre-inductionInductionApneaIntubation stimulusPost-intubationST
AG
ES
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Image from Lifeinthefastlane.com
CAUSES OF HYPOTENSION
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Resuscitation inadequateAcidaemiaPositive pressure (PPV)Induction agentsDisease
HYP
OTE
NSI
ON
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ALL SHOCK STATES ARE NOT
CREATED EQUAL
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HEART-BRAIN AXIS
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VentilationAcidaemiaPressuresOxygenationRegurgitation/ FluidsDA
NG
ERS
Modified from Rich Levitan (@airwaycam)
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Image from Lifeinthefastlane.com
OBJECTIVE #2MAKE A (GOOD) PLAN
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Secure a patent and protected airway without physiological compromise or complications
as rapidly as possible
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Hierarchy of Emergency Intubation Needs(Weingart & Nickson)
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Dunford et al, 2003 PMID: 14634593.
FIRST PASS SUCCESSNO HYPOXIA
NO HYPOTENSION
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You MUST always perform classic RSI!
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DON’T RSI, MODIFY
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DON’T RSI, MODIFYHow about
Resuscitation
Sequence Intubation?
Richard Levitan
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IT IS NOT ALL ABOUT INDUCTION AGENTS
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VentilationAcidaemiaPressuresOxygenationRegurgitation/ FluidsDA
NG
ERS
Modified from Rich Levitan (@airwaycam)
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Pre-inductionInductionApneaIntubation stimulusPost-intubationST
AG
ES
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RESUSCITATE BEFORE YOU INTUBATE
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START INOPRESSORS PERIPHERALLY
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AVOID APNOEA IN SEVERE ACIDAEMIA
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VENTILATE GENTLY
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WATCH CAREFULLYACT FAST
MAKE IT HAPPEN
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Image from Lifeinthefastlane.com
OBJECTIVE #3GET DRUGS RIGHT
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Sunday December 7th, 1941
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ALL INDUCTION DRUGS
CAN CAUSE HYPOTENSION
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DOSING IS MORE IMPORTANT
THAN THE DRUG
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http://en.wikipedia.org/wiki/Ketamine
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http://en.wikipedia.org/wiki/Ketamine
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Image courtesy of pedemmorsels.com
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Shafer, 2004 PMID: 15329579.
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Remember, Shock is
an anaestheti
c!
Rick Dutton
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ETOMIDATEPROPOFOL
THIOPENTONEMIDAZOLAM &
FENTANYLIND
UC
TIO
N
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ETOMIDATEPROPOFOL
THIOPENTONEMIDAZOLAM &
FENTANYLIND
UC
TIO
N
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ETOMIDATEPROPOFOL
THIOPENTONEMIDAZOLAM &
FENTANYLIND
UC
TIO
N
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ETOMIDATEPROPOFOL
THIOPENTONEMIDAZOLAM & FENTANYLIND
UC
TIO
N
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ROCURONIUM OR SUXAMETHONIUM?
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Image courtesy of Cliff Reid
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Image from Lifeinthefastlane.com
SUMMARY
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Hypotension = deathShock is an anaestheticFix the VAPORModify your RSIThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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Hypotension = deathFix the VAPORModify your RSIShock is an anaestheticThe dose makes the drugIf in doubt, rocketamine outAlways have a (good) plan!SU
MM
ARY
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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