Intubating the Hypotensive Patient By: Cindy Oliva Slides adapted from Dr. Nathan Lewis

Wash, Rinse, Repeat Airway management is first for the EM physician. At some point, intubation will become familiar to you. You may get pulled into the habit of just regurgitating standard doses “20 etomidate, 120 sux or 100 rocuronium”. But, not every case is going to be perfect with Mallmpati score of 1 and no obstruction. So What will you do when this patient comes in?

Case Example 45 YOM with unknown PMH struck by car EMS report Pt combative Obvious bilateral open tib-fib fxs Not following commands, abdomen tender BP 90/48, HR 130, RR 28, SpO2 100% on NRB Airway plan?

Hypotension is a bad thing… Post-intubation hypotension higher mortality (33% vs 21%)1 Pre-intubation shock index predictive of post-intubation hypotension (SI > 0.8; SN 67%, SP 80%)2 1Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13. 2Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93. 336 patients intubated in ED, retrospective study, eligible if not hypotensive (<90 SBP) 30 mins prior to intubation 300 patients intubated in ED, retrospective study Hemodynamically unstable or on pressors prior to intubation is the biggest factor associated with death and complications

Resuscitate before you Intubate!!! Consider Volume/Preload Obstructive Causes Limit excessive airway pressures Peri-intubation pressor support Bolus fluids prior to, during and post-RSI Consider obstructive causes like PE which may be contributing to hypotension Limit excessive airway pressure which can decrease Venous return and may be disastrous for a pt who is preload dependent Get push dose pressors ready – phenylephrine: pure alpha, increases in coronary perfusion can improve cardiac output but won’t increase HR or inotropy. Dose is 50 – 200 mcg q2-5 minutes. Push-dose epinephrine is also an option but lots of resistance from nursing and pharmacy because it’s dosing is easy to screw up

Interventions Preoxygenate Bolus fluids before, during and after intubation Consider cause of hypotension Peripheral pressors Phenylephrine Alpha only Increases Cardiac perfusion, improved Cardiac Output No effect on HR Dose : 50 -200 mcg q 2-5 min

Induction Agent All Induction agents can cause hypotension Etomidate causes adrenal suppression Observational study of septic shock patients 60 etomidate vs 42 non-etomidate Mostly succinylcholine for NMB CV collapse = SBP <65 at least once and/or <90 lasting 30 mins despite fluid and/or requiring vasopressors Adrenal suppression linked to increased mortality Jung et al.: Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis. Critical Care 2012 16:R224.

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Induction Agent DECREASE DOSE to 0.5 mg/kg Ketamine As good as etomidate for intubating condition May have desirable hemodynamic effects in patients with hypotension But can cause hypotension at higher doses (>1.5 mg/kg) in catecholamine depleted patients DECREASE DOSE to 0.5 mg/kg Ketamine is the induction agent of choice in the shock patient -least cardio-depressant induction agent available -usually exhibits a stimulatory effect on the cardiovascular system However, it can still cause myocardial depression in the patient with catecholamine depletion. Like the shock patient who’s body has been in Surge mode. This typically occurs at high doses on ketamine.

Paralytic Agent

Succinylcholine Side Effects Increased ICP decrease inotropy Pros Fast onset Short duration Multiple contraindications hyperkalemia (renal failure relative CI) severe sepsis malignant hyperthermia >72 hours after burn crush injuries neuromuscular disease upper motor neuron disorder/injury congenital myopathies Side Effects Increased ICP decrease inotropy Bradycardia increase O2 consumption

Rocuronium BUT, the dose matters! No side effects No contraindications Longer safe apnea times BUT, the dose matters!

What’s the dose?

Bottom Line RESUSCITATE BEFORE YOU INTUBATE Decrease dose of induction agent Ketamine 0.25 – 0.5 mg/kg IV Increase dose of paralytic agent Rocuronium 1.2 mg/kg IV

References Weingart S. Push-dose pressors for immediate blood pressure control. Clinical and Experimental Emergency Medicine. 2015;2(2):131-132. doi:10.15441/ceem.15.010. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93. Jung et al.: Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis. Critical Care 2012 16:R224. Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?. Anaesthesia. 2009;64(5):532-9 Jabre, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicenter randomized control trial. Lancet 2009; 374: 293-300.