Neuroprotective Intubation

Rationale

Minimizes the harmful effects of intubation which include:

ensure adequate preoxygenation and use apnoeic oxygenation
attach ETCO2 to the BVM device; target an ETCO2 that correlates to a PaCO2 of 35-40 mmHg
control hypertension prior to intubation using a rapid acting, titratable antihypertensive agent
consider treatment for intracranial hypertension (if TBI)
- osmotherapy for raised ICP
- analgesia
- head in neutral position and avoid JV constrictions

first pass success
- best intubator
- ear to sternal notch positioning
- head up 30-45 degrees
gentle video laryngoscopy
pharmacologic:
- fentanyl 3-5 mcg/kg (i.e. 150+ mcg)
- remifentanil 1-3 mcg/kg
- topical lidocaine

induction agent
- propofol or thiopentone
  - must decrease dose to avoid hypotension
  - increases cerebral metabolic rate (CMRO2) and cerebral blood flow
- ketamine
  - no longer considered contra-indicated in most patients with raised ICP
  - indirect sympathetic effects may increase blood pressure
  - increases cerebral metabolic rate (CMRO2) and cerebral blood flow
- etomidate is not available in Australia
NMB
- rocuronium 1.2 mg/kg IV is the agent of choice; rapid onset, does not increase ICP

adjust patient’s respiratory rate to target ETCO2 35mmHg until an ABG is obtained to confirm PaCO2 35-40 mmHg
target SaO2 95% (avoid hypoxia or extreme hyperoxia)
use the minimum PEEP necessary to avoid hypoxia