Neuoprotective Intubation Flashcards
The Neurocritical Care or Neuroprotective Intubation can be divided into two categories. What are the two categories? Give examples of patient presentations that fall under each category. (EM Cases - Episode 104, ICH)
- Those that require immediate airway protection. Perform a standard RSI. Examples - herniation, apneic, very low GCS, soiled airway.
- Those that are slowly declining whom you deem a candidate for airway protection. Perform a neurocritical care, neuroprotective intubation. Example - declining GCS, signs of elevated ICP.
Elevated ICP is a concern and one of the reasons you are performing a neuroprotective intubation. List the steps you will take to prepare for intubation of a patient with supected or known elevated ICP.
(ENLS, LITFL, EM Cases)
- Elevate the head of the bed 30 - 45 degrees
during preoxygenation. - Control hypertension prior to intubation. (labetolol or fentanyl for pain management)
- Consider administration of osmotic agents.
(mannitol or 3% HTS) - Avoid hypoventilation - ventilate as necessary
- Avoid hypoxia - oxygenate
- Avoid hypotension - administer volume or vasopressors as needed to treat or prevent hypotension
- Head in neutral position and avoid neck constriction (loosen cervical collar).
How would vou prevent the reflex sympathetic response to intubation during the neuroprotective intubation? (ENLS, LITFL)
- Maintain head of bed elevation
- Ensure first pass success
- Gentle laryngoscopy (use of video laryngoscopy)
- Fentanyl 3-5 mcg/kg (cardiostable
sympatholytic agent, peak effect 3-5 mins) - Lidocaine IV 1.5 mg/kg (weak evidence, may cause hypotension)
- Lidocaine topical (effective at attenuating cardiovascular response to laryngoscopy and intubation)
What are your induction agent choices in a neuroprotective intubation? Explain the pros and cons of the various agents. (ENLS, EM Cases, LITFL)
- Maintain head of bed elevation
- Ensure first pass success
- Gentle laryngoscopy (use of video laryngoscopy)
- Fentanyl 3-5 mcg/kg (cardiostable
sympatholytic agent, peak effect 3-5 mins) - Lidocaine IV 1.5 mg/kg (weak evidence, may cause hypotension)
- Lidocaine topical (effective at attenuating cardiovascular response to laryngoscopy and intubation)
How will you ensure you maintain adequate cerebral perfusion pressure during and after
intubation? What is you MAP goal?
MAP goal: 80 - 110 mmHg (maintain CPP > 60 mmHg)
1. consider a fluid bolus prior to RSI
2. consider ketamine for RSI
3. do not delay vasopressor use for blood pressure goal
What are you mechanical ventilation goals post intubation with a neurocritical care patient?
(ENLS)
- Normalization of oxygenation - maintain a Sp02 > 94% utilizing the lowest Fi02 possible with
PEEP of 5 or greater. - Normalization of ventilation - pH 7.35-7.45, PaCO2 35-45 mmHg or EtCO2 that corresponds to PaCO2 target (33-38 mmHg).
- Normalization of the work of breathing.
- Management of ventilator-patient dyssynchrony.
- Prevention of ventilator induced lung injury - tidal volume 6-8 ml/kg IBW, PEEP 5+.
What are your analgesia and sedation goals post intubation in the neurocritical care patient?
Which medications are recommended? (ENLS, EM Cases)
Goals
1. lowest dose of analgesia and sedation to maintain comfort, ventilator-patient synchrony
2. severe ICP, status epilepticus or the need for ongoing neuromuscular blockade may necessitate deep sedation
Medications
1. start with analgesia - fentanyl or ketamine infusion
2. continuous sedation - propofol infusion preferred, decreases cerebral metabolism
3. consider ketamine if need to maintain MAP and
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What should be included in the focused neurological exam prior to airway management? (ENLS - Airway, Ventilation and Sedation Protocol)
- Level of arousal,
interaction and orientation
(GCS) - Cranial nerve function
- Motor function of each extremitv
- Tone and reflexes
- Sensory level in patients with a suspected spinal cord injury
- Involuntary movements such as tremor or seizure
- Cervical tenderness or gross spinal abnormality
