Talk given at EuSEM 2015 in Torino on the peri-intubation managmeent of critically ill patients in shock

1. Chris Nickson FCICM FACEM
Intensivist, The Alfred ICU
NO APOLOGIES

2. INTUBATION OF THE
SHOCKED PATIENT
http://litfl.org/shock-tube

3. NO CONFLICTS OF INTEREST

4. OBJECTIVES
1 Know what kills
2 Make a (good) plan
3 Get the drugs right

5. NO APOLOGIES
What’s with the title?

6. SUX
TUBE
APOLOGY

7. Image from Lifeinthefastlane.com
OBJECTIVE #1
KNOW WHAT KILLS

8. HYPOTENSION
+
INTUBATION
= DEATH
Photo by Tim Norris, https://www.flickr.com/photos/tim_norris/2538415572
Schwartz et al, 1990 PMID: 7856895

9. Image from Lifeinthefastlane.com
PHYSIOLOGY OF
INTUBATION

10. Pre-induction
Induction
Apnea
Intubation stimulus
Post-intubation
STAGES

11. Image from Lifeinthefastlane.com
CAUSES OF
HYPOTENSION

12. Resuscitation inadequate
Acidaemia
Positive pressure (PPV)
Induction agents
Disease
HYPOTENSION

13. ALL SHOCK STATES
ARE NOT
CREATED EQUAL

14. HEART-BRAIN AXIS

15. Ventilation
Acidaemia
Pressures
Oxygenation
Regurgitation/ Fluids
DANGERS
Modified from Rich Levitan (@airwaycam)

16. Image from Lifeinthefastlane.com
OBJECTIVE #2
MAKE A (GOOD) PLAN

17. Secure a patent and protected airway
without physiological compromise or complications
as rapidly as possible

18. Hierarchy of Emergency
Intubation Needs
(Weingart & Nickson)

19. Dunford et al, 2003 PMID: 14634593.
FIRST PASS SUCCESS
NO HYPOXIA
NO HYPOTENSION

20. You MUST
always
perform
classic RSI!

21. DON’T RSI, MODIFY

22. DON’T RSI, MODIFY
How about
Resuscitation
Sequence
Intubation?
Richard Levitan

23. IT IS NOT ALL ABOUT
INDUCTION AGENTS

24. Ventilation
Acidaemia
Pressures
Oxygenation
Regurgitation/ Fluids
DANGERS
Modified from Rich Levitan (@airwaycam)

25. Pre-induction
Induction
Apnea
Intubation stimulus
Post-intubation
STAGES

26. RESUSCITATE BEFORE
YOU INTUBATE

27. START INOPRESSORS
PERIPHERALLY

28. AVOID APNOEA IN
SEVERE ACIDAEMIA

29. VENTILATE
GENTLY

30. WATCH CAREFULLY
ACT FAST
MAKE IT HAPPEN

31. Image from Lifeinthefastlane.com
OBJECTIVE #3
GET DRUGS RIGHT

32. Sunday December 7th, 1941

34. ALL
INDUCTION DRUGS
CAN CAUSE
HYPOTENSION

35. DOSING IS
MORE IMPORTANT
THAN THE DRUG

37. http://en.wikipedia.org/wiki/Ketamine

38. http://en.wikipedia.org/wiki/Ketamine

39. Image courtesy of pedemmorsels.com

40. Shafer, 2004 PMID: 15329579.

41. Remember,
Shock is an
anaesthetic!
Rick Dutton

42. ETOMIDATE
PROPOFOL
THIOPENTONE
MIDAZOLAM &
FENTANYL
INDUCTION

43. ETOMIDATE
PROPOFOL
THIOPENTONE
MIDAZOLAM &
FENTANYL
INDUCTION

44. ETOMIDATE
PROPOFOL
THIOPENTONE
MIDAZOLAM &
FENTANYL
INDUCTION

45. ETOMIDATE
PROPOFOL
THIOPENTONE
MIDAZOLAM &
FENTANYL
INDUCTION

46. ROCURONIUM OR
SUXAMETHONIUM?

47. Image courtesy of Cliff Reid

48. Image from Lifeinthefastlane.com
SUMMARY

49. Hypotension = death
Shock is an anaesthetic
Fix the VAPOR
Modify your RSI
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

50. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

51. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

52. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

53. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

54. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

55. Hypotension = death
Fix the VAPOR
Modify your RSI
Shock is an anaesthetic
The dose makes the drug
If in doubt, rocketamine out
Always have a (good) plan!
SUMMARY

56. 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