Let's talk some peri-intubation hazards and what you should be thinking about in this setting, focusing on hypotension. If you want to really reinforce it, highly recommend the recent EmCrit podcast (a little dense but helpful) and the RebelEM adjunct (http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/).
Peri-intubation crashing:
First and always the P's
In the addition to the thorough process of P's prior to intubating a patient, consider the HOPs:
* hypotension-- we.ll focus here today
* hypoxia
* acidosis
Hypotension
* ETT/vent --> positive pressure ventilation --> increased RA pressure --> decreased venous return --> decreased preload
* most of these patients are already under a lot of stress with a huge catecholiamine surge propping up the system but also nearly depleting their stores.
* you take this away with induction; this makes ketamine often a better agent
* in shock, paralytics may take longer to work; make sure they're actually circulating
* even if starting with just a soft BP, target a higher number than you might otherwise
* push dose pressor administration vs drip prior to intubation will help prevent peri-intubation crashing;
* epinephrine is the preference for direct cardiac effect