Resuscitate before you Intubate (Resuscitation sequence intubation)
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Steps to Prevent Peri-Intubation Cardiac Arrest
HOP Pneumonic – HOP killers:
Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of peri-intubation morbidity and mortality. Intensivists should focus on correction of these factors prior to intubation.
Bundles to prevent cardiovascular collapse after intubation in the ICU can reduce mortality/morbidity.
Actions to Avoid Peri-intubation Hypotension / Cardiac Arrest:
- Ensure adequate vascular access (CVC, or at least two large bore peripheral IV)
- Fluid resuscitate prior to, and during, rapid sequence intubation (RSI): 1 liter crystalloid IV
- Check fluid balance prior 24 hours and prior shift, if net negative may require additional IV fluids
- Initiate a vasopressor agent (e.g. phenylephrine, norepinephrine) prior to intubation to increase blood pressure before the administration of an induction agent (i.e. shoot for higher than normal BP if possible SBP>140)
- Preoxygenation with at least NRB at 15LMP or HFNC/BIPAP with FiO2 of 100% (can be continuously used during intubation for apneic oxygenation)
- Choose an induction agent and a dose that is least likely to exacerbate hypotension (e.g. ketamine, etomidate)
- Avoid high tidal volumes and dynamic hyperinflation when ventilating, which exacerbates hypotension by decreasing venous return and cardiac output
Post-intubation Hypotension: The AH SHITE mnemonic:
A: Acidosis, Anaphylaxis (check ABG or VBG, evaluate pulse pressure, skin exam)
H: Heart, Tamponade, Pulmonary Hypertension (bedside transthoracic echo)
S: Stacked breaths, Auto-PEEP (check ventilator flow waveforms, measure auto-PEEP)
H: Hypovolemia (rapid IV infusion of 0.5 to 1 liter crystalloid)
I: Induction Agent (treat with vasopressors, phenylephrine, NE, vasopressin, epi)
T: Tension pneumothorax (CXR, needle thoracentesis, tube decompression)
E: Electrolytes (check for hyperkalemia and hypocalcemia, empiric treatment with IV calcium)