The Most Life-Saving Emergency Medicine Articles of 2014

Amal Mattu, MD


December 19, 2014

Tracheal Intubation and Cardiac Arrest

Factors Associated With the Occurrence of Cardiac Arrest After Emergency Tracheal Intubation in the Emergency Department
Kim WY, Kwak MK, Ko BS, et al
PLoS ONE. 2014 Nov 17;9:e112779. doi:10.1371/journal.pone.0112779

We sometimes forget that endotracheal intubation (ETI) itself can produce significant hemodynamic compromise. The induction agents used for intubation can decrease blood pressure, but positive pressure ventilation itself (via mechanical ventilation) also produces a drop in blood pressure by decreasing venous return. In most patients, these hemodynamic changes are not clinically significant, but critically ill patients with limited hemodynamic reserve can rapidly decompensate after a simple ETI.

In this study, Kim and colleagues evaluated critically ill adult patients in the emergency department who were intubated. They found that nearly 2% of patients had a cardiac arrest within 10 minutes. The most important predictor of post-intubation cardiac arrest was systolic hypotension at the time of intubation.

The authors suggest that critically ill patients should receive aggressive pre-intubation fluid resuscitation and/or vasopressors in order to prevent hemodynamic collapse with intubation. Although randomized studies to evaluate this proposal have not yet been done, it certainly seems logical to optimize preload in critically ill patients before ETI whenever possible.


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