AVOIDING THE CRASH: AVOIDING THE CRASH 3: OPTIMIZE YOUR PRE, PERI, - - PDF document

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AVOIDING THE CRASH: AVOIDING THE CRASH 3: OPTIMIZE YOUR PRE, PERI, - - PDF document

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2/16/2014 AVOIDING THE CRASH: AVOIDING THE CRASH 3: OPTIMIZE YOUR PRE, PERI, AND RELAX, OPTIMAL POST-AIRWAY POST AIRWAY MANAGEMENT MANAGEMENT Robert J. Vissers MD Robert J. Vissers MD Chief, Emergency Medicine, Chief, Emergency Medicine,

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SLIDE 1

2/16/2014 1

AVOIDING THE CRASH:

OPTIMIZE YOUR PRE, PERI, AND POST AIRWAY MANAGEMENT

Robert J. Vissers MD Chief, Emergency Medicine, Quality Chair, Legacy Emanuel Medical Center Adjunct Associate Professor, OHSU Portland, OR

AVOIDING THE CRASH 3:

RELAX, OPTIMAL POST-AIRWAY MANAGEMENT

Robert J. Vissers MD Chief, Emergency Medicine, Quality Chair, Legacy Emanuel Medical Center Adjunct Associate Professor, OHSU Portland, OR

Decision to intubate Near death? Unresponsive? Difficult Airway? RSI PHYSIOLOGY ANATOMY TIME

Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management Philadelphia, Lippincott, 2000.

Approach to the Emergency Airway

Post Intubation Management

Intubating the critically ill

  • Planning is critical – no margin for error
  • Assess and plan for difficulty
  • Optimize physiology – focus on prevention of

hypoxia and hypotension

  • Airway may come second
  • Use a checklist – inform the team
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SLIDE 2

2/16/2014 2 View from Haleakala Adult Learner

  • Focus on the life threat
  • Consider ketamine
  • Match ventilation to the disease
  • Prevent delayed complications

Intubating the critically ill

  • 2% risk of cardiac arrest during intubation of

critically ill

  • Significant hypotension common after ETI,

systolic < 80mmHg in 30%, < 70 mmHg in 10% “I need to intubate the patient…but I know he’ll crash when I do.”

Griesdale DEG, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008

Septic shock

  • 32 yo male, hx of paraplegia from GSW, chronic

decubitus ulcers, cocaine and non-compliance

  • In septic shock, maintaining oxygenation
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SLIDE 3

2/16/2014 3 Intubating the critically ill: The Crash

  • Medication induced vasodilatation
  • Reduced catecholamines with sedation and

relaxation Mechanisms of the post- intubation crash:

Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. J Emerg Med 2010

Intubating the shock patient

Optimize physiology - Perfusion

  • Almost all patients need volume
  • 40mL/Kg in kids
  • 1-2 liters in adults
  • May delay intubation if

hypotensive, or hypovolemic and O2 OK – perfusion priority

  • Fluids/pressors

Adult Learner

  • Focus on the life threat
  • Consider ketamine
  • Match ventilation to the disease
  • Prevent delayed complications

Airway in the shock patient

  • Favorite pre-treatment drugs:
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SLIDE 4

2/16/2014 4 What about a “whiff” of pressor?

  • Phenylephrine commonly used in ICU and OR for

transient hypotension

  • Pure vasoconstrictor (no tachy)
  • Peripheral OK
  • Lasts 20 min

What about a “whiff” of pressor?

  • Phenylephrine
  • Need to dilute 100/1 to get 100mcg/mL
  • Push 0.5-2 mL boluses (give it a minute)

Should I use it?

  • Can use diluted epi (1:100,000)
  • http://www.acep.org/content.aspx?id=47948
  • ACEP Weingart March 2010

Etomidate: Adrenal suppression?

  • No prospective studies showing increase in

mortality

  • No outcome data to suggest discontinuation in

emergency RSI

  • Consider hydrocortisone in sepsis
  • Alternative agents may exacerbate shock

Clinical controversies: Etomidate as an induction agent for intubation in patients with sepsis. Ann Emerg Med 2008

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SLIDE 5

2/16/2014 5 Peri-Intubation: Induction agent

Etomidate?

  • 5% decrease (3-8%) in MAP in critically ill

patients, ASA 4

  • Propofol causes 18% decrease (10-25%)
  • Probable associated catecholamine decrease
  • Consider ketamine 2mg/kg as alternative

Minor et al. Procedural sedation of critically ill patients in the emergency department. AEM 2005; 12:124-128.

Etomidate or ketamine?

  • Randomized, controlled study comparing

etomidate and ketamine in critically ill

  • 655 patients
  • Higher percentage of adrenal insufficiency

etomidate group (still 50% in ketamine)

  • No difference in mortality, or morbidity (organ

failure)

Jabre, et al. Etomidate versus Ketamine for RSI in acutely ill patients: a multicentre randomised controlled trial. Lancet, 2009.

Adult Learner

  • Focus on the life threat
  • Consider ketamine
  • Match ventilation to the disease
  • Prevent delayed complications

Induction: Why bother?

  • 32 patients, 2.5 mg/kg ketamine or 5 mg/kg

thiopental

  • 0.6mg/kg rocuronium 2 minutes later
  • Intubating conditions at 60 s acceptable in 50%

with thiopental, 100% with ketamine

  • Jaw relaxation excellent in both groups
  • Vocal cord position significantly worse with

thiopental

Hans P et al. Anaesthesia 1999 Mar; 54:276-9.

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SLIDE 6

2/16/2014 6 Induction: Good for you too

  • In RSI, we are intubating at the leading edge of

the effect of the NMBA

  • Both agent and dose are important
  • Individualize agent to patient condition

Intubating the critically ill: The Crash

  • Air-trapping due to inadequate exhalation
  • Positive Pressure Ventilation causes decreased

venous return Post-intubation ventilation causing:

Intubating the critically ill: The Crash

  • Acidosis from failure to compensate for pre-

existing metabolic acidosis Post-intubation ventilation causing:

Post-intubation in shock

  • Consider acid/base balance before you change

the ventilation

  • Acidosis associated with compensatory

respiratory alkalosis (tachypnea, kussmaul’s)

  • Post intubation ventilate at their RR, “normal

rate” may lead to transient worsening of acidosis

  • Consider bicarb first in ASA poisoning
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SLIDE 7

2/16/2014 7 Adult Learner

  • Focus on the life threat
  • Consider ketamine
  • Match ventilation to the disease
  • Prevent delayed complications

Pediatric asthma

  • Preparation critical!
  • Preoxygenation, fluids
  • Prevent dosing and equipment error –

Broeslow-Luten system

  • Checklist, team plan
  • Prepare for difficult bagging, NG
  • Ventilator settings – permissive hypercapnia, low

rate and tidal volume

Intubating the critically ill: The Crash

  • Elevated plateau pressures exacerbating

barotrauma and ARDS Post-intubation ventilation causing:

Vent settings made simple

Assist control

  • Preset rate and tidal volume
  • Will deliver standard tidal volume
  • Initial mode of choice for respiratory

failure (most ED patients)

  • Less work of breathing than SIMV or

pressure support

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SLIDE 8

2/16/2014 8 Vent settings made simple

Oxygenation

  • Primarily a function of FiO2 and PEEP
  • Start FiO2 of 100%
  • Start PEEP at 5 cm H2O
  • Increase PEEP 2-3 cm q 15 min to increase
  • xygenation

Vent settings made simple

Ventilation (CO2)

  • Primarily a function of RR and tidal volume
  • Maintain pH 7.3-7.4
  • Change in RR greater effect on pCO2 and pH

than tidal volume

Vent settings made simple

Barotrauma/ARDS

  • Primarily a function of plateau pressure (not

peak)

  • Keep plateau pressures below 30 cm H2O
  • Reduce tidal volume in asthma, ARDS, high

plateau pressures (6 cc/kg IBW)

  • Increase peak flow (80-120 l/min)
  • Reduced RR to allow expiration, avoid air

trapping (8-12 bpm)

  • Permissive hypercapnia may be needed

Vent settings made simple

Barotrauma/ARDS

  • Primarily a function of plateau pressure (not

peak)

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SLIDE 9

2/16/2014 9 Peri-intubation: Prevention

Improve outcome beyond the ED

  • Elevate the head of the bed 30-45°
  • Decompress stomach OG
  • Sterile technique with procedures

Post Intubation Sedation

  • Fentanyl 2 mcg/kg IV bolus then
  • 1 mcg/kg/h OR !
  • Hydromorphone 0.5-1 mg IV
  • bolus then repeat q10 min to
  • effect
  • AND !
  • Midazolam 0.05 mg/kg IV bolus
  • then 0.025 mg/kg/hr OR !
  • Propofol 0.5 mg/kg bolus and 20
  • mcg/kg/hr OR ketamine 1 mg/kg
  • bolus then 0.5 mg/kg/h

Adult Learner

  • Focus on the life threat
  • Consider ketamine
  • Match ventilation to the disease
  • Prevent delayed complications

Summary

  • Plan and Prepare
  • Sometimes Airway comes second
  • Assess and manage airway difficulty
  • Consider and optimize physiology
  • Favorite pretreatment? NS, O2, Plan
  • Optimize Post-Intubation management
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SLIDE 10

2/16/2014 10

Thankyou!