Post intubation care

1. Post Intubation Care In the
Emergency Department
Alex Fergie 20-2-14
Alex Fergie 20/2/14

2. How to act like an ED Reg during Intubation
Tube in. Boom! Now act cool and don’t
smile or acknowledge someone who says
well done…Intubation is so boring for you.

3. Immediate post intubation care
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Confirm ETT placement: Attach bag, fogging in the ETT, look for
symmetrical chest rise, listed for equal AE, CO2 trace, Release
cricoid pressure. listen for a leak, CXR confirmation
Continue to hand bag whist someone secures the ETT for you
Have the BP cycling and give 1ml boluses of metaraminol as
needed
Attach ventilator or continue to hand-bag
Recheck ventilator settings
Start sedation infusion (usually propofol 10ml/h) and give 10mg Vec
Get the transport monitoring (5mins), transport 02, transport drugs
and call for the orderly.
Someone holds the lifts and we roll out to ICU…someone called
right??

4. Issues…
• Keep them asleep and keep them
breathing

5. More Issues…
1. Analgesia – ETTs are very irritating/painful
2. Sedation – hypnosis (asleep), anxiolytic,
amnesia
3. Keep them breathing – bag/Oxylog 3000
4. Transfer (people, medications, equipment,
monitoring and make sure your
destination is expecting you)

7. Analgesia
Fentanyl
100x potency of morphine
(10mcg=10mg)
Rapid onset 3-5mins
Sedation
Less histamine itch
Less nausea
Lasts for 30-60mins
Hyoptension/Bradycardia
•Morphine
Lasts longer 2-3hrs
Familiarity (M&M infusions)
Histamine
•Ketamine
Anaesthetic and analgesia
Can ↑ MAP and HR
Sedation
Muscle Relaxants
•Midazolam
•Suxamethonium
Familiarity.
Familiar & Easy to use
Know contraindications
Anterograde amnesia
Only lasts minutes
Decreased systemic vascular
Side effects (↑K, muscle
resistance ↓MAP
pains, MH, Sux apnoea)
•Propofol
no analgesia
rapid onset/offset – minutes
Vasodilatation - ↓ MAP
Apnoea
Familiarity
•Thiopentone
Time to make it up
Less cardiac suppression
Faster onset. Higher
anaphylaxis (1/20000)
•Vecuronium
Familiarity. 10mg lasts
45mins.
Awareness.
Recognising seizures
•Rocuronium (1.2mg/kg)
Reversible with
sugamadex (16mg/kg =
1120mh in a 70kg pt)

8. Scenario 1
1. MVA. Drunk head injured 35yo otherwise
well man. GCS ↓ 14 to 9. Successful
intubation with propofol 200mg and
Suxamethonium 100mg after 3mg of IV
midazolam was given for agitation or
arrival. BP 100/50 HR 100 Needs to go
to the CT then Neurosurg will decide if to
OT or ICU with EVD and ICP monitoring.

9. Analgesia:
Should have given fentanyl 3mcg/kg 3mins prior to
intubation
fentanyl/morphine bolus vs infusion
Sedation:
keep them deep (↓CMRO2) whilst maintaining
perfusion pressure. Propofol infusion 10ml/h (2030mcg/kg/min)
Ventilation:
Volume Control. Tv (6-8ml/kg). Aim for a CO2 = 35-40
(adjust RR (14-20) and No high PEEP to avoid ↑ICPs.
Start with Fi02 100% but quickly reduce to 0.4 aiming
for O2>94%, pO2>70. avoid unnecessary O2.
Transfer Monitoring and Equipment:
things to re-intubate (sux, propofol, blade, ETTs,
bag/mask) things to keep the pt asleep (propofol,
fentanyl), paralysis (vecuronium) CO2 monitoring.

10. Scenario 2
• Second pt from MVA. 70yo with seatbelt
sign. Hypotensive (80/40) and tachycardic
(110).
• Initial VBG (pH 7.1, HCO3 = 10, Lact = 5,
Hb = 50).
• You decide to intubate

11. Analgesia:
fentanyl/morphine ↓ BP. Consider ketamine (bolus
0.5mg/kg) infusion (200mg in 50mls n/s at 0.5mg/kg/hr
for 70kg=9ml/h)
Sedation:
Propofol and BP
again a ketamine infusion would be ideal
Ventilation:
Maybe in metabolic acidosis - large Vt (10ml/kg) and
higher RR (20) to blow of CO2
Transfer Monitoring and Equipment:
things to re-intubate (sux, ketamine, blade, ETTs,
bag/mask) things to keep the pt asleep (propofol,
fentanyl), paralysis (vecuronium) CO2 monitoring.

12. Scenario 3
• Unfortunately you intubate an Asthmatic.
What are the Oxylog 300 settings you would set for your
transfer to ICU.
Pressure vs Volume – need high opening pressures but
variable Tv. EMcrit suggests Volume control Vt 8ml/kg.
But barotrauma a possibilty.
PEEP = 0, I:E ratio = 1:4 or 1:5. Low RR (8-10) to allow
time to expire. watch for breath stacking. Alarming and
drop in Tv consider disconnecting the ETT.
Permissive hypercapnea. Keep pH>7.15 but pCO2 up to 90
can be tolerated by otherwise well pts.

13. Take home messages
1. Use the reference sheet on top of the
intubation trolley.
2. ETTs are painful. Intubated patients need
analgesia more than sedation.
3. Use fentanyl prior to intubating where your BP
tolerates
4. Use Ketamine is you have an unstable patient
5. Think ahead – staff, monitoring, equipment,
drugs, PCAs, O2 cylinders and are ICU
aware?