CRASH & BURN: Airway Management in Hemodynamically Unstable Patients - Part 1

Sep 12, 2024

Dr. Chris Stevens, anesthesiologist and trauma/prehospital airway expert, and Dr. Jeff Jarvis, emergency physician and EMS educator, debate tough airway choices in unstable patients. They explore awareness under paralysis, sedative effects on blood pressure, defining crash airways, and whether to resuscitate before intubation. Transport and supraglottic strategies in bleeding or peri-arrest scenarios are also discussed.

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INSIGHT

Elective Anesthesia Has Lower Awareness Rates

Routine general anesthesia has much lower awareness rates than emergency RSI.
Chris Stevens notes elective cases show awareness under 1% versus higher ED rates due to uncontrolled emergency contexts.

INSIGHT

Longer Paralytics Raise Awareness Risk

Rocuronium use was linked to higher awareness because its paralytic effect can outlast initial sedation.
Jeff Jarvis points out ROC had a five-fold increased odds of awareness compared with succinylcholine in ED-AWARE analyses.

INSIGHT

Standard Sedative Doses Risk Collapse In Sick Patients

Sedative agents like ketamine and etomidate are not reliably hemodynamically neutral in very sick patients.
Chris Stevens warns weight-based dosing from healthy volunteers overestimates needs in elderly or septic patients, risking oversedation and hypotension.

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In this thought-provoking episode of the FlightBridgeED Podcast: MDCAST, Dr. Mike Lauria is joined by Dr. Jeff Jarvis and Dr. Chris Stevens to tackle the critical and potentially controversial topic of airway management in hemodynamically unstable patients. The discussion dives into complex scenarios, decision-making challenges, and balancing the benefits of sedation with the risks of compromising a patient’s stability. From discussing medication-assisted intubation to exploring the concept of "crash airway" situations, the episode challenges conventional wisdom and encourages providers to think critically about their approach to airway management. This episode not only raises important questions but also provides valuable insights for both new and seasoned practitioners.

Some Takeaways to Listen For in this Episode:

Balance Between Sedation and Hemodynamic Stability: It is important to understand how sedative agents like ketamine and etomidate affect blood pressure in critically ill patients. Over-sedation, especially in hemodynamically unstable patients, can lead to adverse outcomes. A nuanced approach to dosing is necessary.
Awareness During Intubation: Awareness under paralysis can increase the risk of PTSD and depression. The conversation highlights the importance of avoiding awareness during airway management, especially using longer-lasting paralytics like rocuronium.
Resuscitate Before Intubate: Emphasizes the need to stabilize patients, particularly their hemodynamics, before intubation. This can prevent worsening outcomes and cardiac arrest during emergency airway procedures.
Decision-Making in Airway Management: Highlights that airway decisions are not black and white. Situational awareness, clinical judgment, and crew confidence are crucial, especially in determining whether to intubate pre-hospital or manage the airway in transit.
Use of Supraglottic Airways: In emergencies where intubation is difficult or risky, supraglottic airways are recommended as a temporary measure to ensure oxygenation and ventilation until more definitive care is available.