EMCrit Podcast Podcast 129 – LAMW: The Neurocritical Care Intubation
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Jul 26, 2014 Exploring the challenges of intubating neurologically critical patients with elevated intracranial pressure, highlighting the importance of precise technique. Strategies for preventing adverse outcomes in traumatic brain injury, aortic dissection, and subarachnoid bleed. Utilizing fentanyl, esmolol, nicardipine, and hypertonic saline to manage blood pressure spikes and intracranial pressure. Benefits of propofol and ketamine mix for stable neurocritical care intubation, emphasizing hemodynamic stability and cerebral metabolic rate reduction.
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Control Blood Pressure First
- Control blood pressure with an infusion before intubation; nicardipine is preferred for stable arterial vasodilation.
- Do not intubate hypertensive neuro patients without addressing extreme BP first.
Lidocaine Is Not Clearly Helpful
- Lidocaine lacks clear evidence for preventing ICP spikes from intubation and may lower blood pressure.
- Topical lidocaine can cause coughing which itself raises ICP, so it is not routinely recommended.
Use High‑Dose Fentanyl Pretreatment
- Pretreat with fentanyl (about 5 mcg/kg) given slowly at least three minutes before induction to blunt sympathetic response.
- Titrate slowly while monitoring breathing and have airway prepared to proceed to RSI if respiration decreases.