Alex Fergie 20/2/14

Post Intubation Care In the Emergency Department

Alex Fergie 20-2-14

How to act like an ED Reg during Intubation

Tube in. Boom! Now act cool and don’t smile or acknowledge someone who says well done…Intubation is so boring for you.

Immediate post intubation care

• Confirm ETT placement: Attach bag, fogging in the ETT, look for symmetrical chest rise, listed for equal AE, CO2 trace, Release cricoid pressure. listen for a leak, CXR confirmation

• Continue to hand bag whist someone secures the ETT for you• Have the BP cycling and give 1ml boluses of metaraminol as

needed• Attach ventilator or continue to hand-bag• Recheck ventilator settings• Start sedation infusion (usually propofol 10ml/h) and give 10mg Vec• Get the transport monitoring (5mins), transport 02, transport drugs

and call for the orderly.• Someone holds the lifts and we roll out to ICU…someone called

right??

Issues…

• Keep them asleep and keep them breathing

More Issues…

1. Analgesia – ETTs are very irritating/painful

2. Sedation – hypnosis (asleep), anxiolytic, amnesia

3. Keep them breathing – bag/Oxylog 3000

4. Transfer (people, medications, equipment, monitoring and make sure your destination is expecting you)

Analgesia Sedation Muscle Relaxants

Fentanyl100x potency of morphine (10mcg=10mg)Rapid onset 3-5minsSedation Less histamine itchLess nauseaLasts for 30-60minsHyoptension/Bradycardia

•MorphineLasts longer 2-3hrsFamiliarity (M&M infusions)Histamine

•KetamineAnaesthetic and analgesiaCan ↑ MAP and HR

•MidazolamFamiliar & Easy to useAnterograde amnesiaDecreased systemic vascular resistance ↓MAP

•Propofolno analgesiarapid onset/offset – minutesVasodilatation - ↓ MAPApnoeaFamiliarity

•Thiopentone Time to make it upLess cardiac suppressionFaster onset. Higher anaphylaxis (1/20000)

•SuxamethoniumFamiliarity.Know contraindicationsOnly lasts minutesSide effects (↑K, muscle pains, MH, Sux apnoea)

•VecuroniumFamiliarity. 10mg lasts 45mins. Awareness. Recognising seizures

•Rocuronium (1.2mg/kg)Reversible with sugamadex (16mg/kg = 1120mh in a 70kg pt)

Scenario 1

1. MVA. Drunk head injured 35yo otherwise well man. GCS ↓ 14 to 9. Successful intubation with propofol 200mg and Suxamethonium 100mg after 3mg of IV midazolam was given for agitation or arrival. BP 100/50 HR 100 Needs to go to the CT then Neurosurg will decide if to OT or ICU with EVD and ICP monitoring.

Analgesia: Should have given fentanyl 3mcg/kg 3mins prior to intubationfentanyl/morphine bolus vs infusion

Sedation: keep them deep (↓CMRO2) whilst maintaining perfusion pressure. Propofol infusion 10ml/h (20-30mcg/kg/min)

Ventilation: Volume Control. Tv (6-8ml/kg). Aim for a CO2 = 35-40 (adjust RR (14-20) and No high PEEP to avoid ↑ICPs. Start with Fi02 100% but quickly reduce to 0.4 aiming for O2>94%, pO2>70. avoid unnecessary O2.

Transfer Monitoring and Equipment:things to re-intubate (sux, propofol, blade, ETTs, bag/mask) things to keep the pt asleep (propofol, fentanyl), paralysis (vecuronium) CO2 monitoring.

Scenario 2

• Second pt from MVA. 70yo with seatbelt sign. Hypotensive (80/40) and tachycardic (110).

• Initial VBG (pH 7.1, HCO3 = 10, Lact = 5, Hb = 50).

• You decide to intubate

Analgesia: fentanyl/morphine ↓ BP. Consider ketamine (bolus 0.5mg/kg) infusion (200mg in 50mls n/s at 0.5mg/kg/hr for 70kg=9ml/h)

Sedation: Propofol and BPagain a ketamine infusion would be ideal

Ventilation: Maybe in metabolic acidosis - large Vt (10ml/kg) and higher RR (20) to blow of CO2

Transfer Monitoring and Equipment:things to re-intubate (sux, ketamine, blade, ETTs, bag/mask) things to keep the pt asleep (propofol, fentanyl), paralysis (vecuronium) CO2 monitoring.

Scenario 3

• Unfortunately you intubate an Asthmatic. What are the Oxylog 300 settings you would set for your

transfer to ICU. Pressure vs Volume – need high opening pressures but

variable Tv. EMcrit suggests Volume control Vt 8ml/kg. But barotrauma a possibilty.

PEEP = 0, I:E ratio = 1:4 or 1:5. Low RR (8-10) to allow time to expire. watch for breath stacking. Alarming and drop in Tv consider disconnecting the ETT.

Permissive hypercapnea. Keep pH>7.15 but pCO2 up to 90 can be tolerated by otherwise well pts.

Take home messages

1. Use the reference sheet on top of the intubation trolley.

2. ETTs are painful. Intubated patients need analgesia more than sedation.

3. Use fentanyl prior to intubating where your BP tolerates

4. Use Ketamine is you have an unstable patient5. Think ahead – staff, monitoring, equipment,

drugs, PCAs, O2 cylinders and are ICU aware?