The lowdown on getting your priorities straight and your doses optimised when tubing a shocked patient.

2. The
Laryngoscope as a
Murder Weapon

3. How to stop killing our
friggin’ patients when
intubating

5. Peri-
Intubation
Deaths are
Preventable

6. Hemodynamics
Oxygenation
Low pH

7. Hemodynamics

8. Case

9. 43 y/o M
Septic
Pneumonia
Sat 96%
BP 62/40

10. Hypotension in the
Peri-Intubation
is Risky
Schwartz et al. Anesthesiology 1995;82:367 and
J Crit Care 2012 Aug;27(4):417

11. Plan
Ahead

12. Meds

13. Induction
Agent

14. Keep ‘em Alive
No Memory
No Pain
No Awareness

15. Keep ‘em
Alive!
No Memory
No Pain
No Awareness

16. All Sedatives will Drop BP in
Shock Patients
J Clin Monit Comput 16(3): 183-190
Anesth Analg 59(5): 355-358

17. I’m
Dying!

18. I’m
Chilling!

19. Negative
to
Positive
Pressure

20. Cardiac stable doesn’t mean
what you think it does

22. Propofol?

24. Etomidate

25. Flat
Hemodynamics

26. Dose

27. Midazolam
+/-
Fentanyl

29. Sympathetic Surge

30. Pain Dosing
Middle Ground
Dissociation

31. Pain Dosing
Middle Ground
Dissociation

32. Hemodynamic
Maintenance

33. Drug Delivery

34. Pain Control

35. emcrit.org/smacc

36. TBI/ICP?

37. Dose Induction based on
plasma volume
&
clinical circumstances

38. Spare discomfort, Spoil life

39. Rick
Dutton
says…

40. Paralytics take longer to
work

41. This sux isn’t working!&!!?

42. Ephedrine Placebo Esmolol
Cardiac Output
9.1 8 5.5
Onset of
Rocuronium 0.6
mg/kg in sec 52 87 114
ActaAnaesthesiol Scand 2003;47(9):1067

43. Sedatives Low
Paralytics High

44. What do I use?

45. Pretreatment
with
Scopolamine
0.4 mg IVP

46. Ketamine
0.25 - 0.5 mg/kg IVP

48. Sux 2 mg/kg
or
Roc 1.6 mg/kg

49. What to do during the
peri-intubation

50. Fluids

51. Shoot for a high BP
BEFORE
Intubating

52. InoPressors

53. Bolus Dose InoPressor

54. Phenylephrine
Epinephrine

55. Phenylephrine
Epinephrine

57. Vent Settings

58. Low & Slow

59. DSI

60. Hemodynamic

61. To Review…

62. Plan Ahead
Dose Smart
PEEP is not always the
solution

63. Plan Ahead
Dose Smart
dd

64. Plan Ahead
Dose Smart
Respond Aggressively

66. Most
Vulnerable Moment

67. The
Laryngoscope as a
Murder Weapon