PHARMACY

A definitive airway is required for effective mechanical ventilation and these patients require sedation – both mechanical ventilation and sedation may make a hypotensive patient more hypotensive and could result in hemodynamic instability. In an under-resuscitated patient, cardiac arrest can occur when induction and paralytic medications are given during rapid sequence intubation.

Be cautious with sedation, advanced airway placement and positive pressure ventilation in patients who are hypotensive or under-resuscitated. Blood pressure can fall rapidly during airway management due to a variety of mechanisms.

Active resuscitation with blood products especially in the hypotensive patient is recommended. Be prepared to support blood pressure with additional fluids and vasopressors (e.g., norepinephrine/epinephrine bolus or drip) if trained or under direct telemedicine guidance.

In all cases, monitor blood pressure (BP) closely (every 1-2 minutes during the procedure, every 3 minutes post-procedure). A BP drop may be brief (if due to vagal effects of epiglottis stimulation during ETT placement) or sustained (if due to loss of sympathetic drive secondary to pain and sedation medications, and/or positive pressure ventilation).