Post Intubation Hypotension
*you intubated someone and they just became hypotensive. Is there more to consider than RSI taking away their inherent sympathetic drive? Think of the “AAHH SHITE” mnemonic the next time you’re in this stressful situation.
Acidosis
· This pH disturbance contributes to a reduction in cardiac contractility/output and arterial vasodilatation leading to hypotension
· Consider administering bicarb peri/post intubation (very controversial)
Anaphylais
· Uncommon in general, but more likely to happen from neuromuscular blocking agents than ketamine/eotmidate
o succinylcholine > rocuronium > atracurium
§ sugammadex (reversal agent for roc) unlikely to reverse the anaphylaxis
Heart: Tamponade
· Consider in both traumatic and nontraumatic (medical) presentatoins
o Suspect in those with history of (recent) malignancy, ESRD, and those on anticoagulation
· These pts are very preload dependent, and by intubating/providing positive pressure ventilation (PPV) you are increasing intra-thoracic pressure thereby decreasing venous return and further declaring the obstructive process
Heart: Pulmonary Hypertension
· PPV+hypoxia+hypercapnea further increase the pulmonary artery pressures and right ventricular pressure
o worsens RV ischemia/overload and bowing into the LV causing decreased LV filling and eventually decreased cardiac output
· In these patients, consider an awake intubation to decrease risk of systemic hypotension from RSI meds as well as hypercapnea secondary to an apneic episode
· Consider ketamine without a paralytic agent as it will maintain respiratory drive
Stacked breaths/autopeep
· Consider in those with obstructive lung pathology who have tendency of breath stacking
o Leads to progressive air trappingà increased intra-thoracic pressureàdecreased preloadàhypotension
Hypovolemia
· Typically in setting of sepsis and hemorrhage
o Give a bolus of appropriate resuscitative fluid
Induction Agent
· Decrease vascular tone and venous return
· Consider ketamine and push dose pressors if patient already hemodynamically unstable
· “Dose Induction Agents Low and Paralytic Agents High”
· Consider awake intubation
o Helps maintain their endogenous catecholamines
Tension PNX
· Endotracheal intubation carries the risk of barotrauma manifesting as a (tension) PNX
· Perform a chest US or CXR if unsure
· Perform a needle/finger thoracostomy if necessary
Electrolytes
· Consider electrolyte derangement(s) such as hyperkalemia if certain medications (succinylcholine) administered and the patient develops a dysrhythmia