Airway Management in Patients With Acute Brain Injury or Ischemia

Airway management and endotracheal intubation are essential skills of emergency medicine. Patients with acute brain injury or ischemia have complex physiology, and without caution, endotracheal intubation can inadvertently lead to secondary brain injury. This article summarizes the evidence behind airway management for patients with acute brain injury or ischemia.

We present data that will help to clarify our recommended actions before, during, and after endotracheal intubation for a patient with acute brain injury or ischemia.

The principles described in this article are centered around avoiding secondary brain injury. Before intubation, it is important to avoid extremes of blood pressure, ensure the patient is preoxygenated, and manage elevated intracranial pressure. We recommend performing a full neurological examination, if feasible. During intubation, using a hemodynamically neutral induction agent such as ketamine or etomidate minimizes the risk of hypotension, which can worsen ischemia. Ketamine was traditionally avoided but has been shown to not affect the cerebral perfusion pressure, and thus is acceptable to use in this patient population. We also recommend the use of video laryngoscopy. Following intubation, we recommend adjusting ventilator settings to target eucapnia. Adequate sedation can assist with the management of intracranial pressure. The use of electroencephalogram (EEG) monitoring can identify non-convulsive status epilepticus.

This evidence-based review of airway management in patients with acute brain injury or ischemia can minimize the risk of secondary brain injury and optimize patient outcomes.