UMEM Educational Pearls

Title: Peri-Intubation Cardiac Arrest

Keywords: endotracheal intubation, cardiac arrest, airway, respiratory failure (PubMed Search)

Posted: 1/2/2018 by Kami Windsor, MD (Updated: 1/4/2018)
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Although the data is limited, current published rates of in-hospital, non-operating room peri-intubation cardiac arrest (PICA) range from 2 to 6%.^1,2,3

Several risk factors associated with PICA have been identified and include:

Preintubation hemodynamic instability (shock index ≥ 1 or systolic blood pressure < 90mmHg)^1,2,3
Elevated Body Mass Index (and increased risk with every 10kg body weight)¹
Use of succinylcholine as paralytic³
Intubation occurring within one hour of nursing shift change³

Other common findings:

Most PICA occurs within 10 minutes of rapid sequence induction (RSI)^1,2
PEA is the initial recorded rhythm 80-100% of the time.^1,2,3
Even if ROSC obtained, PICA is associated with higher rates of in-hospital mortality compared to patients requiring emergent intubation who do not experience cardiac arrest.^1,2,3

Bottom Line: Endotracheal intubation is one of the riskiest procedures we regularly perform as emergency physicians.

Resuscitate hypotensive patients prior to or concomitantly with RSI and/or have a vasopressor at the ready in patients with higher risk of cardiovascular collapse.
Consider use of vecuronium or rocuronium, rather than succinylcholine, in patients who require a paralytic for intubation but are at higher risk of hyperkalemia or have an unknown history.

References

References

1. Heffner AC, Swords DS, Neale MN, Jones AE. Inicidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013; 84(11):1500-4.

2. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2011; 9(11):e112779.

3. Wardi G, Villar J, Nguyen T, et al. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017; 121:76-80.