HOP killers airway management in the patient with difficult physiology 

and then adjust our technique. We assess every patient for difficult anatomy LEMON MOANS SHORT 

But what about the patient with difficult physiology? 

look out for the HOP Killers Hemodynamic instability Oxygen deficit pH (severe metabolic acidosis) 

hemodynamic instability !   Hypotensive, or likely to become hypotensive? !   Attenuation of catecholamines !   Change from negative to positive pressure ventilation !   Hemorrhage, sepsis, obstructive airway disease !   MAP <80 with increased ICP !   Prevent secondary brain injury HOP: 

hemodynamic instability !   Choosing the correct induction agent probably matters less than choosing the correct DOSE. !   Compensated shock: 50% of the normal dose !   Decompensated shock: 10-25% of the normal dose !   Increase dosing of NMBAs to retain rapid onset despite impaired distribution !   Have push dose pressors drawn up; start preloading with fluids early HOP: 

what about hyPERtension? HOP: !   Severe hypertension deserves just as much care in management (a neuroprotective induction) !   Blunt spikes in ICP from laryngoscopy ! Premedicate with lidocaine and fentanyl !   Consider starting with VL ! Etomidate decreases CMRO2 !   Induction agent of choice in encephalopathic patients that are normotensive or hypertensive 

oxygen deficit HOP: !   How do you manage the severely hypoxic patient with no oxygen reserve? !   You’re in the Failed Airway Algorithm before you even start !   “Forced to act:” a newly recognized concept in the Difficult Airway Course 

oxygen deficit HOP: Four complimentary tools to consider: !   CPAP/BiPAP as pre-oxygenation !   Apneic oxygenation during procedure !   DSI (Delayed Sequence Intubation) !   RSA (Rapid Sequence Airway) 

pH/severe acidosis HOP: !   Paralyzing and intubating the patient with severe metabolic acidosis is fraught with danger (Minute volume likely is the only thing keeping them alive) ! Bicarb doesn’t help ! BiPAP or BVM for preoxygenation !   Needs ventilation between paralysis and intubation !   Ventilate starting at 30 bpm: return to pre-intubation EtCO2 or LOWER 

References ! Weingart, S. EMCrit blog and podcast. http://emcrit.org !   Walls, R, and Murphy, M. (2012). Manual of Emergency Airway Management. Lippincott Williams & Wilkins; Fourth edition.