Podcast 104 – Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills - a podcast by Scott D. Weingart, MD FCCM

The Airway Moratorium is Over!

In this podcast I talk about how not to kill the shocked/hypotensive patient in the peri-intubation. I gave this talk at SMACC 2013.



This lecture is part of the Laryngoscope as a Murder Weapon Series:



* Hemodynamic Kills

* Oxygenation Kills

* Ventilatory Kills



Eleni Salakidou's SmaccBYTE Entry



Nickson's Hierarchy of Resus Airway Needs



Literature

Best Review Article



Anaesthesia 2009;64:532



STC Review Article



Curr Anesthesiol Rep 2014;4:225



Hypotension in the peri-intubation is bad and is a source of mortality



Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367)



Heffner et al. J Crit Care 2012 Aug;27(4):417

Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. (PMID 25402500)

Etomidate



Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)



Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)



Ketamine



Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79), in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404) and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)



Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability



A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.



Cats did fine (Canad Anesth Soc J 1975;22(3):339). However if you give 10-100-fold doses to canine heart tissue then maybe (J Cardiovasc Pharmacol 1986;8:414) and (Anesthesiology 1992;76:564), in the latter, dogs got infusions at 25-100 mg/kg/hr.



Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)



Ketamine in ICP (Emerg med australia 2006;18(1):37-44)



Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.

Paralytics

Anesth Analg. 2000 Jan;90(1):175-9.

Other References Reviewed

Other Papers

Intubation in the Shocked Patient

Nickson's Pyramid

courtesy of Chris Nickson

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