ED Intubation


Dangers of intubation - DKA & ASA

It is typically difficult to achieve and maintain the same level of respiratory alkalosis with a ventilator that a strong non-intubated patient can generate.

In severe salicylate intoxication, anything that interrupts hyperventilation will worsen the acidemia and result in deterioration of the patient since an acidemia facilitates the ability of salicylate to cross membranes. Intubation has resulted in catastrophe and cardiac arrest because the patient was not ventilated rapidly enough to maintain the pH at alkaline levels; suppression of the patient's respiratory drive can be rapidly life threatening in this setting (See this EMedHome Clinical Pearl for full discussion). Similarly, intubation can be dangerous in severe DKA since such patients often have extremely low bicarbonate levels, for which they are compensating with a respiratory alkalosis. If there is difficulty intubating the patient, the pH may suddenly fall further.


(2) Krismer AC, et al. Anesth Analg  2001;93(3):734-42.
(3) Simonian SM, et al. Intern Emerg Med 2010;5(5):421-6

Succinylcholine is contraindicated from 72 hrs to 6 months post-spinal cord injury. Why?
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The Answer is:

Because of life threatening hyperkalaemia. Acute denervation causes acetylcholine receptors to spread beyond the motor end plate of the neuromuscular junction, increasing receptor exposure to succinylcholine (See 1/14/15 EMedHome Clinical Pearl).

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