Rapid sequence intubation in the shocked patient

This patient is at high risk of peri-intubation cardiovascular collapse — the single commonest serious event in the INTUBE cohort, occurring in over 40 per cent of critically ill intubations — and the intubation must be planned to prevent it.^[1]

Preparation. Assemble the team and assign roles; lay out and check the equipment (suction, video and direct laryngoscope, a sized endotracheal tube, bougie, supraglottic airway, front-of-neck access kit); draw up the drugs and a vasopressor; connect capnography. Run a pre-induction checklist and call for senior and anaesthetic help early.^[3]

Preoxygenation. Preoxygenate with a tight-fitting mask delivering high inspired oxygen, with apnoeic oxygen continuing through the apnoeic period to extend the safe window.^[1]

Induction and paralysis. Choose a haemodynamically stable induction agent and reduce the dose — the shocked patient has no cardiovascular reserve and a full dose of any agent will precipitate collapse. Ketamine at a reduced dose is preferred, as it preserves sympathetic tone. For the paralytic, rocuronium is a sound choice over suxamethonium in this patient.^[2]

Preventing collapse. Reduce the induction dose; have a vasopressor drawn up and ready to give at induction; avoid a cardiovascular depressant agent; preoxygenate to avoid hypoxia; and limit intubation attempts before changing approach or escalating. Confirm tube placement immediately with capnography.^[1]

After intubation. Sedate and ventilate to a lung-protective target, support the blood pressure, and reassess — a post-intubation blood pressure and lactate confirm whether the resuscitation is on track.^[1]