⚠️ Chapter 21: Intubation in Special Scenarios

Cardiac arrest · Haemodynamic instability (septic/cardiogenic shock) · Foreign body aspiration · UAO (croup/epiglottitis) · Intracranial hypertension · Cervical spine injury · Mediastinal mass · Asthma · Full stomach · Craniofacial abnormalities

🔍 Core Concepts: Intubation in Special Scenarios

🫀 Cardiac Arrest
Intubate immediately, no RSI needed. Continue CPR. Use minimal interruption to compressions.
📉 Haemodynamic Instability
Ketamine (cardio-stable) preferred. Avoid propofol/thiopental. Fluid bolus & vasopressors. If BP unrecordable, intubate awake without muscle relaxants.
🌬️ Foreign Body / UAO
Do NOT blind sweep. Avoid RSI/muscle relaxants (risk of CVCI). Intubate in OT with ENT backup. Use inhalational anaesthesia, smaller ETT.
🧠 Intracranial Hypertension
Avoid hypoxia/hypercarbia/hypotension. Optimize haemodynamics first. Thiopentone/propofol + lignocaine + relaxant. Ketamine safe (recent evidence).
🦴 Cervical Spine Injury
Jaw thrust + inline stabilization. Avoid neck extension. Straight blade laryngoscope. Ketamine preferred. Avoid vasodilators if spinal shock.
⚠️ Mediastinal Mass / Asthma
Mediastinal mass: avoid muscle relaxants (risk of CVCI), preserve spontaneous breathing. Asthma: ketamine + glycopyrrolate, modified RSI, low bagging rates.

🩺 Stepwise Approach: Intubation in Special Scenarios

1
Cardiac arrest
Intubate during CPR without stopping compressions. No drugs for intubation (RSI not required). Confirm ETT with waveform capnography (low EtCO2 indicates poor CPR quality).
2
Haemodynamic instability (shock)
Pre-emptive fluid bolus (20 mL/kg) and start vasoactive infusion. Use ketamine (1-2 mg/kg) ± rocuronium. If unrecordable BP, intubate awake with topical anaesthesia, no muscle relaxant.
3
Suspected foreign body / acute UAO
Do NOT sedate or paralyse. Allow patient to sit upright (tripod). Use inhalational anaesthesia (sevoflurane). Have ENT for rigid bronchoscopy/tracheostomy. Avoid bag-mask ventilation.
4
Intracranial hypertension
Avoid hypoxia, hypercarbia, hypotension. Give isotonic fluid bolus if borderline BP. Induction: thiopentone (5-7 mg/kg) or propofol + lignocaine (1.5 mg/kg) + rocuronium. Ketamine acceptable (maintains CPP).
5
Cervical spine injury
Manual inline stabilization (assistant). Jaw thrust without head extension. Ketamine for induction (maintains BP in spinal shock). Avoid succinylcholine if risk of hyperkalaemia.
6
Mediastinal mass / severe asthma
Mediastinal mass: preserve spontaneous ventilation, avoid muscle relaxants, have ECMO backup. Asthma: ketamine + glycopyrrolate, modified RSI, low bagging rate (6-8 breaths/min) to avoid hyperinflation.