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Case

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A 58-year-old man with a known history of poorly controlled hypertension is evaluated in the emergency department after being found down for an unknown period of time. He has left-sided hemiparesis and neglect, a left frontotemporal scalp contusion, and somnolence. Because the patient could not remember the onset of symptoms and the mechanism of injury is uncertain, a rigid cervical collar is placed by emergency medical services in the field. Computed tomography (CT) of the head demonstrates a large right thalamic intracerebral hemorrhage with intraventricular extension. There is no skull fracture, cervical spine injury, or gross cervical misalignment. During the initial evaluation, he is interactive and able to communicate verbally, and he denies cervical tenderness to a confrontational examination. Just prior to his transfer to the intensive care unit (ICU), he becomes progressively obtunded, with a symmetrical increase in bilateral lower extremity tone. His respiratory status rapidly declines; he is now making grunting noises and actively using his accessory muscles. It is not known when he last ate, and examination of the oropharynx reveals a blunted gag reflex and weak cough.

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Does this patient need to be intubated?

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Certain indications for intubation in the neurocritically ill are similar to other patient cohorts (ie, failure to maintain or protect the airway or failure of oxygenation and or ventilation).1 The indications for immediately securing the airway in our specific patient include the following:

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  1. This patient is a state of acute neurologic decline with a worsening neurologic examination.

  2. He has dangerously dulled airway protective reflexes and is considered to have a full stomach, putting him at risk for large-volume gastric aspiration.

  3. He will likely require additional invasive procedures with sedation (eg, external ventricular drain, intracranial pressure (ICP) monitor placement, or craniotomy).

  4. He will be transported between units and likely will undergo further imaging studies, requiring supine positioning.

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Airway considerations and challenges specific to the neurocritically ill include the following:

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  1. The need to perform serial neurologic examinations makes intermediate- and long-acting sedation and neuromuscular blockade fundamentally undesirable.

  2. Hypoxemia is a potent mediator of secondary brain injury and must be avoided.

  3. In patients with ischemia-reperfusion, such as cardiac arrest, ischemic stroke, and sometimes traumatic brain injury (TBI), hyperoxia (such as occurs when 100% Fio2 is administered to a patient with good cardiopulmonary function) should be avoided: it potentiates reperfusion injury and is associated with worse outcomes.

  4. Hyperventilation increases cerebrovascular tone, acutely decreasing cerebral blood flow, with implications on maintaining cerebral perfusion and managing ICP.

  5. Hypoventilation decreases cerebrovascular tone, increasing cerebral blood volume and acutely driving up ICP.

  6. In neurotrauma, head and facial trauma can create upper airway obstruction, and there is a high incidence of cervical spine injury and instability, placing the cervical spinal cord at risk during intubation and other airway maneuvers.

  7. Patients with acute ischemic stroke are exquisitely sensitivity to changes in hemodynamics, such as the ...

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