Examination

2 points of IV access with consideration given to more access ± arterial line in high-risk/unwell patients
See Airway Assessment
Echocardiography (see Echocardiogram) to review for hypovolaemia, RV dysfunction, LV dysfunction, critical aortic stenosis and/or tamponade
Gastric ultrasound (see: Gastric UltraSound • Image Acquisition)

Optimise Oxygenation

Risk factors for hypoxaemia:
- Obesity or pregnancy
- Pneumothorax
Interventions to consider:
- BiPAP/CPAP for recruitment
- Inhaled pulmonary vasodilator for patients with RV failure or refractory hypoxaemia
- Pleural interventions e.g. thoracocentesis, chest drain

Risk factors for peri-intubation arrest or hypotension:
- Pre-intubation MAP < 75 mmHg
- Shock index > 0.8
- Underlying cardiac disease (e.g. aortic stenosis, right ventricular dysfunction, tamponade)
- BMI > 25, pregnancy or Abdominal Compartment Syndrome
Interventions to consider:
- Noradrenaline or adrenaline
- Target MAP > 80 mmHg prior to intubation
- Arterial line insertion
- Avoid excessive intrathoracic pressure post-intubation:
  - Avoid excessive bag-valve mask ventilation prior to intubation
  - Set the ventilator with low PEEP (5cm) initially, then gradually titrate up (see Mechanical Ventilation)
- Treat hypovolaemia if truly present
- In severe Hypocalcaemia consider giving IV calcium after intubation
  - Avoid calcium boluses prior as it can sometimes cause vomiting
- Stepwise sedation
- Treat RV failure with inhaled pulmonary vasodilators

Risk factors for pH deterioration
- Severe metabolic acidosis (e.g. bicarbonate < 10 mmol/L)
- Robust respiratory compensation with a low $P_{a} CO X_{2}$
Interventions to consider:
- Consider delaying intubation to allow correction of the underlying process
- IV bicarbonate (give >10 minutes before intubation to allow $CO X_{2}$ to be ventilated off)
- Intubate with a large bore ETT to minimise airway resistance