In a hypotensive post intubation patient what changes would you make to help bp
Reduced Peep
Reduce RR or TV
Give IVF if no APO
Pressers
Avoid medications that lower BP like nitrates
Preoxygenation in different scenarios for intubation :
Cooperative, normal TV patient → NRB/HFNO, head-up, 3–5 min, apnoeic O₂ via nasal cannula.
Uncooperative/aggressive but breathing → DSI with ketamine, then NRB/HFNO or NIV, then RSI.
Poor ventilation → NIV or BVM with PEEP, two-person technique, active oxygenation.
Acidosis and respiratory failure → maintain spontaneous breathing, NIV, DSI, minimize apnea, match post-intubation minute ventilation.
“Discuss RSI and ventilation in a patient with X”
“I Prepare Drugs To Ventilate Minds”
I – Indications and risks in this condition
Prepare – Pre-intubation optimization
Drugs – Drug choice and justification
To – Technique modifications
Ventilate – Ventilator settings
Minds – Monitoring and complications
“Avoid High PEEP in :
SHARP Lungs”
S – Shock / hemodynamic instability
H – Hyperinflation (asthma/COPD)
A – Acute RV failure / pulmonary hypertension
R – Raised ICP
P – Pneumothorax / barotrauma risk/Pregnancy
L – Low oxygenation requirement (no need for recruitment)
Difference between adult and pediatric airway :
- Large occiput
- Large tongue
- Large tonsils /adenoids
- Narrow airway
- Shorter trachea
- Larynx more higher and anterior
- Epiglottis long and floppy
- Narrowest part of airway is below the vocal cords
- Reduced FRC
- Increased metabolic/oxygen demands
Sux Relative Contraindications:
“Septic Muscles Raise Pressure”
Septic – Severe sepsis
Muscles – Myopathies
Raise Pressure – High ICP or IOP
Sux Absolute Contraindications:
“Hot Muscles Burn, Crush Spines, Stroke Eyes”
Hot – Malignant hyperthermia
Muscles – Neuromuscular disease (ALS, MS, GBS)
Burn – Burns >24 hours
Crush – Crush injury >24 hours
Spines – Spinal cord injury >72 hours
Stroke – Stroke with paralysis >72 hours
Eyes – Penetrating eye injury / open globe
Hyper K – Hyperkalaemia or risk of it
Pseudo – Pseudocholinesterase deficiency
Sux Shock – History of severe sux reaction
Indications of RSI :
- Failure to maintain or protect airway
○ GCS ≤ 8, loss of airway reflexes
○ Massive facial trauma, burns, airway obstruction (if still intubatable) - Failure of oxygenation or ventilation
○ Severe hypoxia despite maximal non‑invasive support
○ Hypercapnic respiratory failure not responding to NIV - Anticipated clinical course
○ Need for definitive airway in trauma, sepsis, shock, status epilepticus, raised ICP, etc. - High aspiration risk
○ Full stomach, bowel obstruction, pregnancy, upper GI bleed
CI to RSI:
(relative—true “no RSI” is rare)
- Cannot ventilate, cannot intubate anticipated and no surgical airway backup
- Extremely difficult airway where awake technique is safer (e.g. severe angioedema, massive supraglottic tumor, RA with severe deformity)
- Profound hemodynamic collapse without resuscitation/vasopressors ready
- No ability to monitor or confirm tube (no ETCO₂, no suction, no backup)
DSI Indications
- Severely hypoxic, agitated, uncooperative patient who: ○ Cannot tolerate mask, NIV, or HFNC
○ Is ripping off oxygen
○ Needs intubation but cannot be safely preoxygenated in current state
Typical examples:- Hypoxic pneumonia/ARDS patient fighting mask
- Agitated head injury with hypoxia
- Severe metabolic acidosis patient hyperventilating but combative
CI to DSI :
- Imminent arrest / peri‑arrest → go straight to RSI or crash intubation
- True “can’t intubate, can’t oxygenate” anatomy → need awake/surgical airway, not DSI
- Ketamine contraindications (rare, but include: known ketamine allergy, some specific psychiatric states where dissociation is problematic—though in ED airway, benefit usually outweighs risk, head injury with herniation ,increased intraocular pressure like glaucoma ))
*No staff or time to monitor during dissociation
