Lignocaine premedication before rapid sequence induction in head injuries
Date First Published:
March 1, 2000
Last Updated:
November 11, 2002
Report by:
John Butler, SpR in Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Rupert Jackson, Manchester Royal Infirmary
Three-Part Question:
In [head injured patients with signs of raised intracranial pressure who need RSI and ventilation] is [pretreatment with lignocaine better than placebo] at [attenuating the rise in intracranial pressure associated with RSI]?
Clinical Scenario:
A patient attends the emergency department having sustained a blunt head injury. On examination they have clinical signs of raised intracranial pressure and a Glasgow Coma Score of 5. You decide that the patient needs a rapid sequence intubation and contiuous mandatory ventilation in order to protect the airway and reduce intracranial pressure. You wonder whether the pretreatment with lignocaine will attenuate the rise in intracranial pressure from the rapid sequence intubation.
Search Strategy:
Medline and Embase 1966-07/02 using the OVID interface.
Search Details:
[exp Lidocaine OR lidocaine$ OR lignocaine$] AND [exp Intracranial pressure OR intracranial pressure.mp OR ICP.mp] LIMIT to human AND English.
Outcome:
85 papers found of which 3 were relevant to the question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Donegan MF, Bedford RF. 1980, USA | 10 ventilated comatosed patients on ICU. IV Lignocaine 1.5mg/Kg vs N/Saline | Double blind PRCT | Change in ICP on suctioning | Lignocaine attenuated rise in ICP | Small numbers Patients not paralysed |
| A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. White PF, Schlobohm RM, Pitts LH, et al. 1982, USA | 15 comatosed patients with diffuse axonal injury on ICU. Compared response to suction with: | RCT | Change in baseline ICP | Reduced with lidocaine and thiopentone | Small numbers unblinded Questionable randomisation |
| Change in ICP on suctioning | No effect | ||||
| Effect of lidocaine on ICP response to endotracheal suctioning. Yano M, Nishiyama H, Yokota H, et al. 1986, USA | 9 patients with severe head injury (GCS<8). All patients had mild cranial high BP. All ventilated | RCT compared response on suctioning. IV lignocaine vs intratracheal lignocaine. Readings at 1,3,5,10,15 mins | Comparison of routes | Intratracheal route more effective | Unblinded Small numbers Patients not paralysed |
| Change in ICP on suctioning | Both methods reduced ICP | ||||
| Change in baseline ICP | No change in baseline ICP |
Author Commentary:
Some 40-60% of patients with coma producing brain injuries will have intracranial hypertension. The National Emergency Airway Course recommends a pre-treatment dose of Lignocaine (1.5mg/kg) given 3 minutes before induction when intubating head injured patients. Analysing the results of the above search there appears to be little high quality evidence available to show that intravenous lignocaine suppresses the rises in intracranial pressure associated with rapid sequence intubation in head injured patients.
Bottom Line:
There is no high quality evidence to support the use of a pre-treatment dose of lignocaine in addition to neuromuscular blockade in head injured patients requiring a rapid sequence intubation (RSI) in the emergency department. Its use remains controversial.
References:
- Donegan MF, Bedford RF.. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning.
- White PF, Schlobohm RM, Pitts LH, et al.. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning.
- Yano M, Nishiyama H, Yokota H, et al.. Effect of lidocaine on ICP response to endotracheal suctioning.