Post-Intubation Management

1. Post Intubation Care in ED
J.Tembo
14 Aug 2014

2. Whew!

3. Check
• Tube is in correct position
• Patient comfortable & as Physiologically
normal as possible
• Aims for intubation achieved

4. Tube in correct position
• Continuous wave form EtCO2
• Depth 22-24cm
• Cuff pressure 20-30cm H20 use Cufflator
• Secured -tie unless raised ICP
• CXR

5. Patient Safe
• Protective lung ventilation
• Raise head of bed 30-45 degrees
• Sats
• FiO2
• Analgesia
• Sedation
• NGT
• IDC
• Eye care

6. Oxygenation & Ventilation
• Ventilator settings
– Mode
– TV
– RR
– FiO2
– PEEP
– PS
– I:E
– Plt P
• Bloods gases

7. Watch out
• Tachypnoea
• Tachycardia
• Diaphoresis
• Hypoxia
• Tears

8. The Behavioral Pain Scale

9. Sedation,Analgesia,Paralysis
• M & M infusion
• Propofol
• Ketamine
• Vecuronium
– 0.1mg/kg
– 0.06mg/kg/hr

10. Pretreatment
3 – 5 minutesprior to intuba on
o Fentanyl 3mcg / kg
o for High ICP / Vascular (eg
dissec on) / preeclampsia or
eclampsia with elevated BP
o Consider Lignocaine 1.5mg / kg
o for High ICP / Vascular with elevated BP
Immediate “pushdose” Inotrope or Vasopressor
o Adrenaline 10mcg/ml = 1:100000; dose 0.5-2ml (5-20mcg as required 1-5 minutely)
o In 10ml syringe draw up 9ml normal saline; now draw up 1ml of 1:10000 adrenaline (from prefilled
syringe) and shake = 1:100000.
o Label syringe “Adrenaline 10mcg/ml”; discard the other syringe.
o Metaraminol 0.5mg/ml; dose 1-2ml (0.5-1mg as required 2-5 minutely)
o In 20ml syringe draw up 19ml normal saline; now draw up 1ml of 10mg/ml Metaraminol and shake
o Label syringe “Metaraminol 0.5mg/ml”
EmergencyDepartment Useful References
This checklist is for informa onal purposes only.
ALL informa on must be ve ed with your clinical judgment, pharmacy and hospital
commi ees & regula onsModified from EmCrit Intuba on Checklist Dr James Rippey 2013 Review 2016
Drug
Normotensive
dose
Normotensive dose
in 70kgpa ent
Hypotensive
dose
Ketamine 2mg/kg 140mg 0.5mg/kg
Thiopentone 3-5mg/kg 300mg 0.5-1mg/kg
Propofol 1.5-3mg/kg 150mg 0.2mg/kg
Suxamethonium 1.5-2mg/kg 100mg 2mg/kg
Rocuronium For RSI 1.2mg/kg 85mg 1.6mg/kg
Sugammadex
16mg/kg reversal of
rocuronium 2min post
administra on
1120mg
As 100mg/ml solu on
In 2 or 5ml vials
16mg/kg
Intuba on Drugs
Ini al post intuba on analgesia / seda on infusions
Ini al Ven lator Se ngs
Contraindica onsto Suxamethonium
o Malignant hyperthermia history
o Strokes with hemiparesis > 72 hours
o ICU stay > 2 weeks
o Burns / trauma > 72 hours
o NMJ disease
o Myopathies / Muscular dystrophies
o Hyperkalaemia (known or suspected)
o Guillain-Barre
o Penetra ng eye injury and acute glaucoma
Infusion Dose Mixer Bolus Rate Indica on
Morphine &
Midazolam
50mg
50mg
50ml NS
0.05
ml/kg
0.05-0.1 ml / kg / hr
70kg adult = 5 ml / hr
Maintain analgesia &
seda on
Propofol
500mg
(50ml)
0.5
mg / kg
20-30 mcg/kg/min
70kg adult = 10 ml / hr
Stable, with severe
neurologic injury.
Ketamine 200mg 50ml NS 0.5mg/kg
0.5mg/kg/hr
70kg adult = 9 ml / hr
Unstable
Se ngs
Normal
Lungs
Asthma /
COPD
ARDS/ ALI
type lungs
Severe
metabolic
acidosis
Severe
Head
Injury
Mode Volume
FiO2
Start at 100% and trate down rapidly ideally achieving FiO2 0.4
Aim for oxygen sats > 94%; pO2 > 70; avoid significant hyperoxia. Aim Pplat < 30
Vt ml/
kg IBW
6-8 5-6 6 10 6-8
RR 14 8-10 14 20 16
PEEP 5
Asth
0
COPD
5
5 - 10 5 5
I:E ra o 1:2 1:4 – 1:5 1:2 1:2 1:2
Notes
Maintain
homeo-
stasis and
avoid
lung
injury
Watch for
breath
stacking,&
barotrauma
Consider
permissive
hypercapnea
Watch
pressures; may
need to lower Vt
and accept
higher CO2
Titrate FiO2 &
PEEP
Maintain
respiratory
compen-
sa on for
acidosis.
Watch for
gas trapping
Avoid
high PEEP
Aim
PCO2
35-40
SEDATIONPARALYSIS
Adjust as per clinical & ABG assessment
Seek ICU advice if concerns

11. Case 1
• M 33,previously well ,BIBA
• 2hrs post Amitryptylline overdose >20mg/kg
• GCS 14 and deteriorating
• P 140 ,BP 90,Sats 96%
• ECG= sinus tachycardia

12. Case 2
• F/65,lives alone, BIBA
• COPD, still smokes, domiciliary O2
• Large pack of Meds + discharge summaries
• Resp arrest at triage
• Bag mask ventilation by Ambos
• P66,Sats 72,BP

13. Case 3
Non Cardiogenic APO

14. Pretreatment
3 – 5 minutesprior to intuba on
o Fentanyl 3mcg / kg
o for High ICP / Vascular (eg
dissec on) / preeclampsia or
eclampsia with elevated BP
o Consider Lignocaine 1.5mg / kg
o for High ICP / Vascular with elevated BP
Immediate “pushdose” Inotrope or Vasopressor
o Adrenaline 10mcg/ml = 1:100000; dose 0.5-2ml (5-20mcg as required 1-5 minutely)
o In 10ml syringe draw up 9ml normal saline; now draw up 1ml of 1:10000 adrenaline (from prefilled
syringe) and shake = 1:100000.
o Label syringe “Adrenaline 10mcg/ml”; discard the other syringe.
o Metaraminol 0.5mg/ml; dose 1-2ml (0.5-1mg as required 2-5 minutely)
o In 20ml syringe draw up 19ml normal saline; now draw up 1ml of 10mg/ml Metaraminol and shake
o Label syringe “Metaraminol 0.5mg/ml”
EmergencyDepartment Useful References
This checklist is for informa onal purposes only.
ALL informa on must be ve ed with your clinical judgment, pharmacy and hospital
commi ees & regula onsModified from EmCrit Intuba on Checklist Dr James Rippey 2013 Review 2016
Drug
Normotensive
dose
Normotensive dose
in 70kgpa ent
Hypotensive
dose
Ketamine 2mg/kg 140mg 0.5mg/kg
Thiopentone 3-5mg/kg 300mg 0.5-1mg/kg
Propofol 1.5-3mg/kg 150mg 0.2mg/kg
Suxamethonium 1.5-2mg/kg 100mg 2mg/kg
Rocuronium For RSI 1.2mg/kg 85mg 1.6mg/kg
Sugammadex
16mg/kg reversal of
rocuronium 2min post
administra on
1120mg
As 100mg/ml solu on
In 2 or 5ml vials
16mg/kg
Intuba on Drugs
Ini al post intuba on analgesia / seda on infusions
Ini al Ven lator Se ngs
Contraindica onsto Suxamethonium
o Malignant hyperthermia history
o Strokes with hemiparesis > 72 hours
o ICU stay > 2 weeks
o Burns / trauma > 72 hours
o NMJ disease
o Myopathies / Muscular dystrophies
o Hyperkalaemia (known or suspected)
o Guillain-Barre
o Penetra ng eye injury and acute glaucoma
Infusion Dose Mixer Bolus Rate Indica on
Morphine &
Midazolam
50mg
50mg
50ml NS
0.05
ml/kg
0.05-0.1 ml / kg / hr
70kg adult = 5 ml / hr
Maintain analgesia &
seda on
Propofol
500mg
(50ml)
0.5
mg / kg
20-30 mcg/kg/min
70kg adult = 10 ml / hr
Stable, with severe
neurologic injury.
Ketamine 200mg 50ml NS 0.5mg/kg
0.5mg/kg/hr
70kg adult = 9 ml / hr
Unstable
Se ngs
Normal
Lungs
Asthma /
COPD
ARDS/ ALI
type lungs
Severe
metabolic
acidosis
Severe
Head
Injury
Mode Volume
FiO2
Start at 100% and trate down rapidly ideally achieving FiO2 0.4
Aim for oxygen sats > 94%; pO2 > 70; avoid significant hyperoxia. Aim Pplat < 30
Vt ml/
kg IBW
6-8 5-6 6 10 6-8
RR 14 8-10 14 20 16
PEEP 5
Asth
0
COPD
5
5 - 10 5 5
I:E ra o 1:2 1:4 – 1:5 1:2 1:2 1:2
Notes
Maintain
homeo-
stasis and
avoid
lung
injury
Watch for
breath
stacking,&
barotrauma
Consider
permissive
hypercapnea
Watch
pressures; may
need to lower Vt
and accept
higher CO2
Titrate FiO2 &
PEEP
Maintain
respiratory
compen-
sa on for
acidosis.
Watch for
gas trapping
Avoid
high PEEP
Aim
PCO2
35-40
SEDATIONPARALYSIS
Adjust as per clinical & ABG assessment
Seek ICU advice if concerns

16. End

17. References
• http://scghed.com/wp-content
accessed 12 Aug 14
• EMCrit Podcast 84-The Post
Intubation Package-
• EMCrit Podcast 115-A new
Paradigm for Post
Intubation pain,Agitation
and Delirium
• Basic Assessment &Support
in Intensive Care