Podcast 129 – LAMW: The Neurocritical Care Intubation - a podcast by Scott D. Weingart, MD FCCM

This is the another of the Laryngoscope as a Murder Weapon lectures; though in this case it is really more of an aggravated assault.

Who is this For?

Semi-elective intubations for patients with presumed or known elevated ICP



In TBI severity of brain injury doesn’t predict the lack of need for pharmacological blunting of increase in MAP or ICP [cite source='pubmed']23511147[/cite]



The prototypical case requiring this treatment is a high-grade SAH prior to securing the aneurysm



This is the same way we would intubate an aortic dissection patient

Preoxygenation

Ap Ox and high-flow fiO2 for the full 3 minutes or longer

ETCO2

Put it on the BVM

Non-Pharmacologic Methods to Blunt Reflex Response

Limit time of laryngoscopy and atraumatic laryngoscopy



Leave the patient upright until the last possible moment, then intubate in 20 degrees head-up



No-touch intubation with video laryngoscopy by the best intubator

Pretreatment

Control the BP BEFORE the intubation

Lidocaine

While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results.[cite source='pubmed']11696494[/cite] Literature is pretty good on endotracheal suctioning, but nothing on patient-important outcomes during intubation. Not hemodynamically active in this one study, but I have experienced radical drops in BP. [cite source='pubmed']22633717[/cite] This one shows the hypotension potential. [cite source='pubmed']25237632[/cite]



Local is more effective than IV. [cite source='pubmed']10861151[/cite]



Lidocaine References [cite source='pubmed']11696494[/cite], [cite source='pubmed']17358099[/cite], [cite source='pubmed']23683444[/cite], [cite source='pubmed']7772359[/cite],

Fentanyl

Dose 5 mcg/kg [cite source='pubmed']6318605[/cite], [cite source='pubmed']7032347[/cite]



All equipment meds must be prepared before administration. Someone must be watching the pt. You need to have push-dose epinephrine drawn up at the bedside if you are going to use fentanyl in these doses.

Remifentanil

Remifentanil can also be used, but I don't have so I can't speak about it

Esmolol

Dose 1.5-2 mg/kg ~ 3min beforehand



Combo of Esmolol and Fentanyl [cite source='pubmed']1363221[/cite]



[cite source='pubmed']7788827[/cite]



[cite source='pubmed']9084524[/cite],[cite source='pubmed']1672488[/cite]

Nicardipine

Dose 20 mcg/kg (average 1.4 mg)



[cite source='pubmed']21696933[/cite] and [cite source='pubmed']10553821[/cite] and Review Article (16978041)

Other Group's Recs

At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: they state prefasiculation is dead

Osmotic Therapy

Probably a good time to give a dose of hypertonic saline

Induction Agents

Etomidate, Propofol, or Propofol/Ketamine (75%/25%). If Thiopental was still available, it would be on the list as well.

Muscle Relaxants

Rocuronium or Succinylcholine at full dose

Post-Intubation Sedation

Propofol and Fentanyl

Post-Intubation Ventilation

Shoot for 95% saturation, use PEEP only if necessary; but if it is necessary it is safe to use



Increase Respiratory Rate until ETCO2 of 35 mm Hg; then send a blood gas

Other Situations

Basilar Stroke and Stuttering Stroke-lower bp=screwed

Review Article

Has anyone found a good one for ICP



Here is a great article for the EMCrit Podcast

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