cardiac assessment and resuscitation in the peri-intubation period
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Your need to intubate may have a negative impact on a cardiovascular system that is already in shock. Learn how to assess and support heart function BEFORE intubation to avoid cardiovascular collapse in the peri-intubation period and beyond.
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at the intersection of cardiac physiology & Intubation
The impact of positive pressure
How will your decision to intubate impact the heart of a critically ill patient? In order to be prepared for the consequences of the procedure of intubation you need to first know what effect that procedure will have. We explain it here.
Contractility
Apical 4 Chamber View
To evaluate RV contractility, the first step is to get a good apical four chamber view. Is the RV bigger than the LV?
Preload
Assessing Volume Status
A plethoric IVC suggests a volume overload state or obstructive pathology (tamponade, PE). >50% collapse with inspiration or compression suggests euvolemia or hypovolemia. The RV is preload dependent to an extent, but excess fluid can quickly overload the RV and worsen RV dysfunction–so consider vasopressors early.
Venous Congestion
The Vexus Score
Not convinced by your IVC ultrasound? The Venous Excess Ultrasound grading system can help provide additional information to evaluate fluid status.
RV FUNCTION
how bad & acute or chronic
POCUS can be used to quickly evaluate for RV dysfunction and potential cardiovascular collapse in the peri-intubation period. The apical 4-chamber view and TAPSE are key components of assessing the RV.
measuring tapse
Tricuspid annular plane systolic excursion or (TAPSE) has a strange name but is simple to measure. It’s done in the apical 4 chamber view using m-mode. We show you how to do it here. Is the measurement less than 1.6cm? That means poor contractility.
Inotropes
Decreased RV contractility and poor systemic perfusion despite optimizing preload and using vasopressors? Consider adding an inotrope.
Afterload
pH, PaO2, and PCO2
Pulmonary vasodilation, or decreased PVR, will reduce afterload for the right ventricle. Oxygen is a potent pulmonary vasodilator, meaning pre-oxygenation should be optimized for patients with RV failure in the peri-intubation period. Hypercapnia will increase PVR and RV afterload. NIPPV can be used to improve both oxygenation and ventilation peri-intubation, but beware of using excess PEEP.
Pulmonary Vasodilators
Oxygen is the ultimate pulmonary vasodilator, but O2 isn’t enough there are pharmacologic options that can be considered to decrease pulmonary vascular resistance (PVR).
Instructions
- Look for this tabletop card & snap the QR code.
- Begin with the self-guided resources to practice in a judgement free zone
- Connect with a remote coach
- Work with an in person coach at one of our live events.
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What’s Next
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