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Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member
The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a beneficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.