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Airway Management in TBI or Ischemia

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Written by Vivian Lei

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This is a concise, evidence-based approach to intubating patients with acute brain injury while minimizing secondary brain injury and preserving cerebral perfusion.

Mindful Intubation
Emergency airway management in patients with acute brain injury or ischemia poses unique challenges, with a risk of causing secondary brain injury. Here’s how to optimize outcomes in this high-risk population.

  • Primary goal- Prevent secondary brain injury from hypoxia, hypotension, hyper/hypocarbia, or increased intracranial pressure (ICP).
  • Before intubation-
    • Perform a rapid but thorough neurological exam (GCS, pupils, motor function, speech).
    • Optimize oxygenation with preoxygenation (NRB, HFNC, NIPPV, or BVM) and apneic oxygenation.
    • Avoid hypotension. Maintain MAP 80–100 mmHg. Individualize based on the patient’s baseline BP.
    • Address suspected ICP elevation while preserving cerebral perfusion pressure (CPP). Elevate head of bed 30°, avoid jugular compression, ensure proper cervical collar fit.
  • During intubation-
    • Consider fentanyl (2–3 mcg/kg) as a sympatholytic to blunt laryngoscopy response when safe. Lidocaine is not recommended.
    •  Use rapid-sequence induction (RSI) with hemodynamically neutral agents, such as etomidate or ketamine (now considered safe and may reduce ICP).
    • Succinylcholine is preferred for shortened paralysis unless there is a contraindication. Rocuronium is acceptable with awareness of prolonged effect.
    • Maintain eucapnia during BVM via waveform capnography.
    • Video laryngoscopy is recommended to improve first-pass success and reduce complications.
  • After intubation-
    • Set ventilator settings for pH 7.3–7.4, PCO2 35–45 mmHg, SpO2 >95%, tidal volume 6-8 cc/kg, and initial PEEP of 5-8 cmH20.
    • Reserve hyperventilation (target PCO2 30–35 mmHg) for brief ICP crisis management, paired with ICP lowering therapy (hypertonic saline, mannitol).
    • Provide adequate analgesia and sedation to prevent agitation and ICP spikes.
      • Propofol + fentanyl is preferred if hemodynamically stable. Consider adding low-dose vasopressor (e.g. norepinephrine) for mild hypotension.
      • Use midazolam if significant hypotension.
      • Ketamine or dexmedetomidine are useful as adjuncts for patients requiring multiple sedative agents.
    •  Delay antihypertensives until after pain/anxiety is addressed to avoid hypotension.
    •  Initiate continuous EEG when possible to detect non-convulsive seizures.

How does this change my practice?
The practical framework provided in this article stresses the importance of individualizing the approach to each brain-injured patient, with the goal of minimizing secondary brain injury. This allows a physician to consider the nuance of pharmacologic strategies (ketamine is OK!), intubation techniques (VL>DL), and post-intubation considerations (sedation first, consider EEG).

Source
Airway Management in Patients With Acute Brain Injury or Ischemia. J Emerg Med. 2025 Jul;74:125-133. doi: 10.1016/j.jemermed.2024.12.015. Epub 2025 Jan 6. PMID: 40348691

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