What is the best Rapid Sequence Intubation (RSI) medication to use for a patient with intracranial hemorrhage, considering their past medical history, including any history of hypertension, anticoagulant use, or previous intracranial hemorrhage?

Rapid Sequence Intubation for Intracranial Hemorrhage

For patients with intracranial hemorrhage requiring RSI, use etomidate (0.2-0.3 mg/kg IV) as the induction agent followed by rocuronium (1.0-1.2 mg/kg IV) as the neuromuscular blocking agent. 1, 2

Induction Agent Selection

Etomidate is the preferred induction agent for intracranial hemorrhage because it decreases intracranial pressure (ICP) without compromising cerebral perfusion pressure (CPP). 3

• Etomidate 0.2 mg/kg IV significantly reduces ICP in patients with intracranial lesions while maintaining hemodynamic stability 3
• In hemodynamically compromised patients with ICH, reduce the dose to 0.15 mg/kg to minimize cardiovascular effects 2
• Etomidate provides excellent intubating conditions in 88.1% of emergency department patients undergoing RSI 4
• The Society of Critical Care Medicine found no mortality difference between etomidate and other induction agents (ketamine, propofol, midazolam) in critically ill patients 1

Why Not Ketamine for ICH?

While ketamine is an acceptable alternative induction agent for general RSI, etomidate is specifically superior for intracranial hemorrhage due to its ICP-lowering properties. 3

• Ketamine (1-2 mg/kg IV) can be used if etomidate is unavailable, but lacks the proven ICP reduction benefit 2, 5
• Historical concerns about ketamine increasing ICP have been refuted when used with controlled mechanical ventilation, making it acceptable but not optimal 6, 5
• In critically ill patients with depleted catecholamine stores (common in severe ICH with shock), ketamine can paradoxically cause hypotension despite its sympathomimetic properties 5

Avoid Propofol

Propofol should be avoided in ICH patients as it causes the most profound hypotension among induction agents, which can critically reduce cerebral perfusion pressure. 1, 6

Neuromuscular Blocking Agent Selection

Rocuronium 1.0-1.2 mg/kg IV is the preferred NMBA for ICH patients requiring RSI. 2, 7

• High-dose rocuronium (1.0-1.2 mg/kg) provides excellent intubating conditions within 60-90 seconds, comparable to succinylcholine 7
• Rocuronium avoids the fasciculations associated with succinylcholine that can transiently increase ICP 2
• When using high-dose rocuronium, ensure sugammadex is immediately available for reversal in a "can't intubate, can't ventilate" scenario 2
• Wait at least 60 seconds after rocuronium administration before attempting intubation to ensure adequate neuromuscular blockade 2

Succinylcholine Alternative

Succinylcholine (1.5 mg/kg IV based on actual body weight) can be used if rocuronium is unavailable, but the fasciculations may transiently increase ICP 2

Critical Hemodynamic Management

Have vasopressors immediately available during RSI, as post-intubation hypotension is common and associated with increased mortality, prolonged ICU stays, and organ dysfunction. 6

Blood Pressure Targets for ICH

Target systolic blood pressure <140 mmHg in patients with intracerebral hemorrhage to reduce hematoma expansion. 1

• Labetalol is the preferred antihypertensive for acute BP control in ICH as it maintains cerebral blood flow and does not increase ICP 1
• Nicardipine and sodium nitroprusside are acceptable alternatives for BP management 1
• Avoid acute BP reduction >15% of mean arterial pressure in the first 24 hours unless BP is severely elevated (>220/120 mmHg) 1

Anticoagulation Reversal Before RSI

If the patient is anticoagulated, urgently reverse anticoagulation before or concurrent with RSI. 1

Warfarin Reversal

• Administer 4-factor prothrombin complex concentrate (PCC) plus vitamin K 10 mg IV 1

Heparin Reversal

• Administer protamine sulfate 1 mg per 100 units of heparin given in the previous 2-3 hours (maximum 50 mg single dose) 1

LMWH Reversal

• For enoxaparin given within 8 hours: protamine 1 mg per 1 mg of enoxaparin (maximum 50 mg) 1
• For enoxaparin given 8-12 hours prior: protamine 0.5 mg per 1 mg of enoxaparin 1

Direct Oral Anticoagulants (DOACs)

• For dabigatran: administer idarucizumab 1
• For factor Xa inhibitors: administer 4-factor PCC or andexanet alfa if available 1

Antiplatelet Agents

• Discontinue antiplatelet agents immediately 1
• Platelet transfusion is suggested only if neurosurgical intervention is planned and platelet function testing confirms dysfunction 1

Common Pitfalls to Avoid

Never administer an NMBA without first giving a sedative-hypnotic induction agent, as this causes awareness during paralysis, which occurs in approximately 2.6% of emergency intubations. 1, 6

Do not use ideal body weight for dosing—use actual body weight for all RSI medications. 2

Do not administer corticosteroids following etomidate for the purpose of counteracting adrenal suppression, as multiple RCTs showed no mortality benefit. 1, 2

Ensure full neuromuscular blockade before attempting intubation to prevent coughing or movement that could increase ICP and worsen hemorrhage. 2