# Lidocaine for ICP



## lakerzfan36 (Aug 5, 2010)

Has anyone ever heard or tried administration of lidocaine prior to rapid sequence induction, regular orotracheal intubation, or suction in traumatic patients with increased intracranial pressure?


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## waterdog (Aug 5, 2010)

Yes , we use it for the reasons you described here in NC.

We also use it for Ventricular Dysrhythmias. 1.5mg/kg IV/IO

Its used quite often , with positive results. Its part of our protocols.


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## Cawolf86 (Aug 6, 2010)

I haven't personally used it since I am just a student AND it is not used in my county - but it is my state regs. Lido is indicated for Cardiac Arrest normally but a note in our pharm manual says that it "May decrease ICP response during laryngoscopy for intubation". Our dosage as well is 1-1.5 mg/kg IV/IO with a repeat of 0.5-0.75 mg/kg every 5-10 min with a max of 3 mg/kg.


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## Smash (Aug 6, 2010)

waterdog said:


> Yes , we use it for the reasons you described here in NC.
> 
> We also use it for Ventricular Dysrhythmias. 1.5mg/kg IV/IO
> 
> Its used quite often , with positive results. Its part of our protocols.



Positive results? In what way?

Despite it's popularity, there is no evidence that lidocaine has any effect in attenuating rises in ICP during RSI and I am not aware of any services near me that use it.  Nor, for that matter, is there any evidence that it is of any benefit in cardiac arrest. It has largely been supplanted by amiodarone in cardiac arrest, although the basis for this is rather tenuous (the ARREST and ALIVE trials).


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## akflightmedic (Aug 6, 2010)

Damn you and your evidence based medicine!!! Who cares about those studies, who??

I have lots of anecdotal evidence which we all know is way better than well documented, reproducible, scientific research!

(Much like another field as well, but I digress)


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## Smash (Aug 6, 2010)

akflightmedic said:


> Damn you and your evidence based medicine!!! Who cares about those studies, who??
> 
> I have lots of anecdotal evidence which we all know is way better than well documented, reproducible, scientific research!
> 
> (Much like another field as well, but I digress)



Dammit, you're right! Give me "expert" opinion and "I met this guy once, and he said that at s conference some other guy said that his medical director reckoned that this was a good idea" any day!


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## Akulahawk (Aug 6, 2010)

lakerzfan36 said:


> Has anyone ever heard or tried administration of lidocaine prior to rapid sequence induction, regular orotracheal intubation, or suction in traumatic patients with increased intracranial pressure?


Yes, I've heard of the use of Lido in that setting...


Cawolf86 said:


> I haven't personally used it since I am just a student AND it is not used in my county - but it is my state regs. Lido is indicated for Cardiac Arrest normally but a note in our pharm manual says that it "*May decrease ICP response during laryngoscopy for intubation*". Our dosage as well is 1-1.5 mg/kg IV/IO with a repeat of 0.5-0.75 mg/kg every 5-10 min with a max of 3 mg/kg.


To me that note above, in bold, indicates simply that lidocaine _may_ decrease the ICP response during laryngoscopy. It does _not_ indicate that it actually _does_.

I would imagine that enrolling someone in an efficacy trial might just require that person already have an ICP monitoring bolt in place... and that person might just already have confounding issues that might just skew any results... IOW: the person might be more, or less, sensitive to the laryngoscopy stimulus and therefore have a potentiated or no response...

I certainly wouldn't volunteer to have an ICP bolt put in my head, just purely for research, for the purpose of measuring the effect of laryngoscopy and endotracheal intubation has...


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## reaper (Aug 6, 2010)

Most up to date RSI protocols removed Lidocaine a few years back. There was no studies that proved it helped in any way.


 We do not even want to dwell on the Lido vs Amnio debate.


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## Smash (Aug 6, 2010)

reaper said:


> We do not even want to dwell on the Lido vs Amnio debate.



*Backs slowly out of the thread taking his comments about any drug therapy in cardiac arrest with him...* h34r: 

Seriously though, lidocaine has no proven role in RSI. Most protocols call for an opioid such as fentanyl (or sufentanyl or remifentanyl or something) to provide a slight degree of rapid onset sedation, but mostly to blunt sympathetic response to laryngoscopy, plus a hypnotic of some sort such as versed or etomidate (largely this is personal preference, all having different positives and negatives) followed by neuromuscular blockade of choice (again, largely personal preference, there are arguments for and against suxamethonium or a non-depolarizer like rocuronium)
Ketamine is catching on as a good alternative to th benzo type hypnotics, and I suspect that this will become more popular due to it's unique properties and versatility. 
RSI definitely has a place in managing TBI. I have seen presented (but not yet published) data from an Australian study that demonstrated a clear and significant benefit in outcomes for people who received pre-hospital RSI over in hospital RSI - the trouble with previous studies has been that the procedure was not carried out well, with hypoxia, hypotension and hypercapnia being common, followed by hyperventilation and hypocapnia. When these things are controlled for, outcomes are excellent with RSI.


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## Cawolf86 (Aug 6, 2010)

reaper said:


> Most up to date RSI protocols removed Lidocaine a few years back. There was no studies that proved it helped in any way.
> 
> 
> We do not even want to dwell on the Lido vs Amnio debate.



Yes, here in CA Amiodarone is the drug of choice generally - with Lidocaine still being in the scope as a replacement.


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## BLSBoy (Aug 6, 2010)

Why push more meds then you have to?
Etomidate decreases ICP. 
http://www.cjem-online.ca/v4/n3/p194


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## boingo (Aug 6, 2010)

We generally add Fentanyl prior to Etomidate during the induction process, as well as a defasiculating dose of Vecuronium to mitigate any rise in ICP during laryngoscopy in the TBI patient.


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## Smash (Aug 7, 2010)

boingo said:


> We generally add Fentanyl prior to Etomidate during the induction process, as well as a defasiculating dose of Vecuronium to mitigate any rise in ICP during laryngoscopy in the TBI patient.



Not to bang on about this EBM nonsense, but do you have any evidence that 1) sux causes a clinically significant rise in ICP or 2) that fasciculations cause a clinically significant rise in ICP and 3) that the non-depolarizing dose is anything other than a nice, but ultimately futile idea? 

The use of agents like lidocaine or non-depolarizers prior to induction and paralysis was not orginally about management of ICP, it was about managing post fasciculation myalgias in operative patients. 

Generally speaking, if I am RSI'ing a patient it is a 'need to do' situation. Given the lack of evidence for these pre-treatment agents I would consider the time spent waiting for the 'nice to do' things like that to be not worth the wait. That, however, is purely my opinion, not evidence!


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## MrBrown (Aug 7, 2010)

We only carry 2% lignocaine for pre-IV cannulation; waste of bloody time never used it, never seen it used.

If you are going to be given drugs before we stuff a tube down your gob you get fentanyl and either midaz (neruogenic cause for coma with GCS <10) or ketamine (everybody else).


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