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Lignocaine premedication before rapid sequence induction in head injuries
  1. John Butler, Specialist Registrar,
  2. Rupert Jackson, Specialist Registrar,
  3. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}man.ac.uk

    Abstract

    A short cut review was carried out to establish whether pretreatment with lignocaine (lidocaine) reduces the rise in intracranial pressure associated with intubation of head injured patients. Altogether 85 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by John Butler, Specialist Registrar
 Checked by Rupert Jackson, Specialist Registrar

    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 continuous mandatory ventilation 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.

    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]?

    Search strategy

    Medline and Embase 1966–07/02 using the OVID interface. [exp Lidocaine OR lidocaine$.mp OR lignocaine$.mp] AND [exp Intracranial pressure OR intracranial pressure.mp OR ICP.mp] LIMIT to human AND English AND remove duplicates.

    Search outcome

    Altogether 85 papers were found of which three were relevant to the question. These are shown in table 5.

    Table 5

    Comment(s)

    Some 40%–60% of patients with coma producing brain injuries will have intracranial hypertension. The National Emergency Airway Course recommends a pretreatment dose of lignocaine (1.5 mg/kg) given three minutes before induction when intubating head injured patients. Analysing the results of the above search there seems 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 pretreatment dose of lignocaine in addition to neuromuscular block in patients with head injuries requiring a rapid sequence intubation in the emergency department. Its use remains controversial.

    Report by John Butler, Specialist Registrar
 Checked by Rupert Jackson, Specialist Registrar

    References

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