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

2. 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?

3. 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?

4. 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 ;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):
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

5. 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

6. 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 : mcg q 2-5 min

7. 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 :R224.

8. Lifeinthefastlane.com

9. 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.

10. Paralytic Agent

11. 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

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

13. What’s the dose?

14. 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

15. References
Weingart S. Push-dose pressors for immediate blood pressure control. Clinical and Experimental Emergency Medicine. 2015;2(2): doi: /ceem
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):
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 :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: