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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.
[exp Lidocaine OR lidocaine$ OR lignocaine$] AND [exp Intracranial pressure OR intracranial pressure.mp OR ICP.mp] LIMIT to human AND English.

Search Outcome

85 papers found of which 3 were relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
White PF 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
Yano M 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

Comment(s)

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.

Clinical 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

1. Donegan MF, Bedford RF. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology 1980:52:516-8.
2. White PF, Schlobohm RM, Pitts LH, et al. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology 1982:57(3):242-4.
3. Yano M, Nishiyama H, Yokota H, et al. Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 1986:64(5):651-3.