Intubation of the Neurologically Injured Patient

Bucher, Joshua; Koyfman, Alex

doi:10.1016/j.jemermed.2015.06.078

Cited by 24 publications

(15 citation statements)

References 70 publications

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“…gentle bag‐mask ventilation) to facilitate adequate pre‐oxygenation . Use an i.v. induction agent combined with an opioid to ablate the sympathetic response to intubation, and neuromuscular blockade to avoid an increase in ICP . For trauma patients, ketamine may be the best choice of induction agent, as the preservation of systemic arterial blood pressure will outweigh any theoretical concern about cerebral stimulation ; modify dose in unstable patients. Neuromuscular monitoring, attached before induction, will indicate that neuromuscular blockade has been achieved before intubation. Use a laryngoscope (or videolaryngoscope) with which you are familiar (similar proviso for other equipment used for difficult intubation). Use the target blood pressure values summarised in Table . A transduced direct (invasive) arterial pressure waveform (with the transducer placed at the level of the tragus) will facilitate a stable haemodynamic induction; if time does not allow for invasive monitoring before intubation, NIBP measurement at 1‐min intervals is recommended for the peri‐induction period.

Indications for tracheal intubation in brain‐injured patients GCS ≤ 8 Significantly deteriorating conscious level (e.g.

…”

Section: Preparation For Transfermentioning

confidence: 99%

Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

et al. 2019

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Summary The location of care for many brain‐injured patients has changed since 2012 following the development of major trauma centres. Advances in management of ischaemic stroke have led to the urgent transfer of many more patients. The basis of care has remained largely unchanged, however, with emphasis on maintaining adequate cerebral perfusion as the key to preventing secondary injury. Organisational aspects and training for transfers are highlighted, and we have included an expanded section on paediatric transfers. We have also provided a table with suggested blood pressure parameters for the common types of brain injury but acknowledge that there is little evidence for many of our recommendations. These guidelines remain a mix of evidence‐based and consensus‐based statements. We have received assistance from many organisations representing clinicians who care for these patients, and we believe our views represent the best of current thinking and opinion. We encourage departments to review their own practice using our suggestions for audit and quality improvement.

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Indications for tracheal intubation in brain‐injured patients GCS ≤ 8 Significantly deteriorating conscious level (e.g.

…”

Section: Preparation For Transfermentioning

confidence: 99%

Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

et al. 2019

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“…While our patient received lidocaine, evidence supporting its role in blunting a potential increase in intracranial pressure has not been supported in recent literature reviews and its use is not mandatory (13). For sedation, we employed etomidate, but consideration should be given to ketamine, as the traditional concerns about its impact on intracranial pressure have been questioned and it avoids potentially harmful hypotension associated with other medications (14). In our patient, intubation resolved the negative-pressure ball-valve mechanism that was causing the air leak through his open depressed orbital fracture and allowed for resolution of the tension pneumocephalus by the time of surgical repair.…”

Section: Discussionmentioning

confidence: 97%

Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report

L'Hommedieu

Dingeldein

Tomei

et al. 2018

The Journal of Emergency Medicine

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A 13-year-old male sustained facial trauma from a motor vehicle collision and was found to have tension pneumocephalus on computer tomography. The patient underwent immediate rapid sequence intubation without preceding positive pressure ventilation in the emergency department. At the time of his craniotomy, the tension pneumocephalus was found to have resolved and he went on to have a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Any patient with facial or head trauma and pneumocephalus is at risk for the potential development of tension pneumocephalus. When present, we advocate that aggressive definitive airway management by rapid sequence intubation without preceding positive pressure ventilation and early surgical management should be prioritized.

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“…Ketamine, having the advantage of maintaining a neutral hemodynamic profile, may be safely used. 31 Etomidate may have an edge over other induction agents in this regard. However, in light of the uncertainty over the clinical significance of the adrenal suppression associated with it and the frequent occurrence of sepsis in patients with major trauma, the available evidence suggests that ketamine should be considered as an alternative induction agent or as an adjunct to other intravenous (IV) agents.…”

Section: Traumatic Brain Injurymentioning

confidence: 99%

Ketamine: A Neuroanesthesiologist's Friend or Foe?

Luthra

Rath

2018

Journal of Neuroanaesthesiology and Critical Care

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Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, introduced into clinical practice six decades ago, has often been the worst fear of a neuroanesthesiologist due to its concerns of causing a rise in intracranial pressure and increasing cerebral blood volume. However, the recent literature clarifies that it may have a beneficial role, even in neurosurgical patients, because of its propensity to cause neuroprotection through antiglutamatergic action on the NMDA receptors in the ischemic brain. Apart from having an anticonvulsive role in refractory status epilepticus, its inherent property of increasing blood flow to the ischemic areas offers protection to the penumbral zone, thus preventing secondary brain injuries. Also, it has been widely used as an analgesic at subanesthetic doses post spine surgeries. Recently, enough scientific evidence has been published in favor of ketamine establishing the fact that it does not cause a rise in intracranial pressure when the patient is mechanically ventilated and normocarbia is maintained. It has also been used during evoked potential monitoring as it amplifies signals even under general anesthesia and proves to be quite effective during neuromonitoring. However, its adverse effects of increasing muscle tone, excessive salivation, emergence delirium, agitation, and “out of body” experiences with long-term psychomimetic effects and potential to cause addiction have precluded its widespread use.This review on ketamine summarizes the benefits of using it in neurosurgical anesthesia with the aim of removing the fears we had in the past, which did not seem to be evidence based.

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Intubation of the Neurologically Injured Patient

Cited by 24 publications

References 70 publications

Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

Guidelines for safe transfer of the brain‐injured patient: trauma and stroke, 2019

Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report

Ketamine: A Neuroanesthesiologist's Friend or Foe?

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