VENTILATIONMedication Choices
Induction Agents - #1 priority is keeping them alive (pain, memory, awareness are #2,#3, #4)
**Remember, all sedatives will drop BP in shock patients**
They are freaking out right before intubation, so when you knock them out, you lose those sympathetics (9 inch nails becomes Bob Marley)
Going negative to positive pressure ventilation causing reduced preload
Propofol “sometimes the white just ain’t right” dose reduced 90% (150 -->15mg in shocky patient)
Etomidate - ignoring the steroid suppression debate, he says you need MORE etomidate to get same levels in the brain in a shock patient (Singer may disagree here) - Weingart doesn’t use etomidate because if you ½ the dose they may be aware, and remember you eek!
Midazolam +/- fentanyl - effects are 3-5 minutes, so no effect during RSI, then after intubated will have some effect (praying for retrograde amnesia) AVOID!, Ok maybe give low dose versed 3-5 minutes before intubating
Ketamine, LOVE IT, gives a sympathetic surge.
- Pain Dosing .1-.2mg/kg
- Middle ground - Perfect for shocky patient intubation so maybe 30-50 IV??
- Dissociative dose - 1-2mg/kg (so 70-140 IV, or 210-300 IM)
Faster onset than propofol/etomidate, so you will see effects IMMEDIATELY
It’s also an analgesic! And good for TBI! (if shocky)Let’s Talk Paralytics
These also have a longer time of onset in a shocky patient (onset is cardiac output dependent)
Dose higher (remember sedatives go low!)
PRETREAT - Scopolamine .4mg IVP 10-15 minutes beforehand, only side effect is tachycardia, which is perfect.
Ketamine ½ dose - .5mg/kg, so 35mg in a 70kg patient
High dose of Succ (2mg/kg) or Roc (1.6mg/kg) so 140Succ or 112RocPeri-intubation
Give fluids (shoot for higher than normal BP because you will drop it during RSI), shoot for systolic 140, MAP 80
So start on inopressor drip before intubating (if NE drip needed), or even just hook them up, set pump at 0, if they start to drop BOOM pump started, also have push dose pressor (Epinephrine) ready before intubation, Not Phenyl!Vent Settings
Start low on pressures/PEEP
6cc/Kg TV (420 in 70 kg patient)
DSI
Push small amount of ketamine to check BP drop (but won’t stop their breathing), push 20, some patients only need 20, then paralytic, then tube!
Now if they drop with 20, know you need more pressor support (fluids, NE drip/push dose) (