lidocaine pretreatment in head trauma tubes

[Hamhock]

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Anyone know of any good evidence for the use of lidocaine pretreatment when tubing for head trauma?

HH

 

[Hawkeye Kid]

I led a journal club on this last year, so as of then I was up to speed with all of the lit on the topic (I don't know of anything new).

Basically, there is no convincing evidence that lido, defasciulating doses of non-depol. NMBs, fentanyl, or anything else has an impact on M&M. All of the studies--most of which are pretty old--are either OR or ICU based and show attenuation of increasing ICP with either intubation or deep tracheal suctioning. I can't recall any study that has shown an outcome effect.

Here's a decent review from BMJ:

http://emj.bmj.com/cgi/content/full/18/6/453

 

[Planktonmd]

Anyone know of any good evidence for the use of lidocaine pretreatment when tubing for head trauma?

HH

Are you referring to Lidocaine IV before intubating a patient with head trauma?
The benefit: Questionable at best.
The risk: lower seizure threshold.
Risk > Benefit.

If you mean topical Lidocaine to the airway before intubating then it is a good idea and might prevent the increase in ICP if you have to intubate awake for some reason.
The best plan of action: Induce anesthesia properly and intubate deep.

 

[DoctorMedic]

shouldn't using etomidate really be more beneficial for ICP than lido anyway?

 

[Hamhock]

shouldn't using etomidate really be more beneficial for ICP than lido anyway?

yeah, it's still etomidate and sux (or some combo like that)
but with lido too

 

[Apollyon]

yeah, it's still etomidate and sux (or some combo like that)
but with lido too

Not sux if there is a head bleed - that will increase ICP. Go with vec or roc.

 

[McPoyle]

Not sux if there is a head bleed - that will increase ICP. Go with vec or roc.

How big of a risk is this?

The reason I ask is that pre-hospitally, sux is still our go to paralytic if needed. Granted we are moving away from using paralytics at all if we can. I know more than one of my drug facilitated intubations have been pt's I suspected of having a head bleed, now I'm concerned... In these pt's should we be skipping sux and going right to vec if we suspect a bleed or is the risk minimal enough for us not to worry about it?

 

[southerndoc]

How big of a risk is this?

The reason I ask is that pre-hospitally, sux is still our go to paralytic if needed. Granted we are moving away from using paralytics at all if we can. I know more than one of my drug facilitated intubations have been pt's I suspected of having a head bleed, now I'm concerned... In these pt's should we be skipping sux and going right to vec if we suspect a bleed or is the risk minimal enough for us not to worry about it?

Actually the act of intubating itself (through laryngoscopy) causes increases in ICP.

 

[Arcan57]

Vec takes longer to work and also lasts much longer, which are not good things with head injured patients. The morbidity and mortality associated with hypoxia in the setting of head injury argues for getting the tube in the fastest and most efficacious way possible. For the majority of patients that's going to be sux/etomidate. Especially in the setting of extremely weak data regarding actual impact of sux vs. a non-depolarizer on outcome in this population.

 

[southerndoc]

Vec takes longer to work and also lasts much longer, which are not good things with head injured patients. The morbidity and mortality associated with hypoxia in the setting of head injury argues for getting the tube in the fastest and most efficacious way possible. For the majority of patients that's going to be sux/etomidate. Especially in the setting of extremely weak data regarding actual impact of sux vs. a non-depolarizer on outcome in this population.

Rocuronium remains a good alternative. Quick onset (45s-1m) and doesn't last as long as vecuronium (30 mins or so).

I use a lot of rocuronium for dialysis patients, crush injuries, and even septic patients if I think they're in acute renal failure and have a possibility of hyperkalemia.

 

[WilcoWorld]

I've transitioned away from Sux to almost always using Roc. The benefits of Roc are many, and the main benefit of Sux - short acting - is not that important to me, since once it wears off I still am left with a patient who needs mechanical ventilation and/or airway protection, so why do I care if they're unparalyzed 15 minutes earlier?

 

[southerndoc]

I've transitioned away from Sux to almost always using Roc. The benefits of Roc are many, and the main benefit of Sux - short acting - is not that important to me, since once it wears off I still am left with a patient who needs mechanical ventilation and/or airway protection, so why do I care if they're unparalyzed 15 minutes earlier?

I think a lot of people are worried about can't intubate/can't ventilate situations with rocuronium.

If I have a perceived high-risk intubation, I won't use rocuronium. Luckily we have access to a Glidescope, so if I have a truly difficult intubation I can do a semi-awake intubation with it. If I paralyze somebody and can't ventilate, then somebody is getting a cric.

 

[Arcan57]

In head injured patients, I've found that the sooner NS can get an exam the more likely the patient is to go to the OR. I have found myself using a lot more high dose (0.3 mg/kg) vec for RSI outside of head injury due to not having i-Stat/POC renals and a relatively high percentage of dialysis/undx'ed renal failure patients. We have to get roc from pharmacy, which limits its utility.

southerndoc, are situations where you'll use sux but not roc for RSI? My thought is that if I don't think I can ventilate the guy I'm not paralyzing them with anything.

 

[southerndoc]

southerndoc, are situations where you'll use sux but not roc for RSI? My thought is that if I don't think I can ventilate the guy I'm not paralyzing them with anything.

SCH remains my primary paralytic. If I perceive a difficult intubation, I usually will do a sedation only intubation using a Glidescope. I use rocuronium primarily in dialysis patients, crush injuries, head injuries, etc. (luckily it's stocked in the hospital-wide RSI kit because our intensivists love it).

 

[aphistis]

In head injured patients, I've found that the sooner NS can get an exam the more likely the patient is to go to the OR. I have found myself using a lot more high dose (0.3 mg/kg) vec for RSI outside of head injury due to not having i-Stat/POC renals and a relatively high percentage of dialysis/undx'ed renal failure patients. We have to get roc from pharmacy, which limits its utility.

southerndoc, are situations where you'll use sux but not roc for RSI? My thought is that if I don't think I can ventilate the guy I'm not paralyzing them with anything.

1) 30mg is a LOT of vecuronium for a 100kg patient.

2) It's much easier to say on a leisurely internet forum than in the middle of crunch time, and you obviously have to be both very careful identifying them and very confident in your airway exam, but there are some patients who are much easier to paralyze & intubate than they are to mask ventilate. Note: I'm just throwing this out for consideration; I would never fault someone for wanting to establish ventilation prior to paralyzing & intubating.

 

[Arcan57]

30mg is a lot, but if you want someone paralyzed right this minute and don't have sux/roc readily available then that's the dose that gets the job done. Most of the (avoidable) airway disasters I've seen have involved bagging with emesis/aspiration between the period of sedation and paralysis. My feeling is that if you're going to paralyze someone, you want that time period to be as short as possible. The trade-off being that the pt is going to be paralyzed for (usually) hours at that dose.

 

[McPoyle]

Actually the act of intubating itself (through laryngoscopy) causes increases in ICP.

This was my understanding as well, thats why I was surprised to see the mention of the medication and not the physical action to be responsible for raising ICP.

 

[Apollyon]

The decision to use roc/vec instead of sux for a head bleed was reinforced to me by a neurosurgeon I respect greatly.

With a blown pupil and obtundation, yet still breathing and/or seizing, a paralytic to get the tube in trumps the exam, as, as long as the pt was normal/seminormal prior to the event, the NSurgeon is taking the patient to the OR. Tube before the CT, too.

 

[aphistis]

30mg is a lot, but if you want someone paralyzed right this minute and don't have sux/roc readily available then that's the dose that gets the job done. Most of the (avoidable) airway disasters I've seen have involved bagging with emesis/aspiration between the period of sedation and paralysis. My feeling is that if you're going to paralyze someone, you want that time period to be as short as possible. The trade-off being that the pt is going to be paralyzed for (usually) hours at that dose.

True all. Fair enough.

 

[nimbus]

30mg is a lot, but if you want someone paralyzed right this minute and don't have sux/roc readily available then that's the dose that gets the job done. Most of the (avoidable) airway disasters I've seen have involved bagging with emesis/aspiration between the period of sedation and paralysis. My feeling is that if you're going to paralyze someone, you want that time period to be as short as possible. The trade-off being that the pt is going to be paralyzed for (usually) hours at that dose.

Why wouldn't you have sux and roc readily available? Do you practice in the United States? Hi dose vec is not the drug of choice for RSI not least because it takes time to mix up. If I were in your situation I would talk to your pharmacy about making sux and roc readily available.

 

[Arcan57]

Sux is readily available in my ED, but there are contraindications that can make it inappropriate for a particular patient. High-dose vec is an option if you don't have roc, and is discussed in Walls' airway book.

 

[aphistis]

Sux is readily available in my ED, but there are contraindications that can make it inappropriate for a particular patient. High-dose vec is an option if you don't have roc, and is discussed in Walls' airway book.

It shouldn't be hard for a pharmacy to keep you well-supplied with roc. Is there are reason yours sometimes doesn't? 100mg of rocuronium will quickly provide intubating conditions as good as you're going to find anywhere, and the patient will come off of/allow reversal from 100mg of roc in much less time than 30mg of vec. I'm just curious.

 

[deleted65604]

Anybody know when the reversal agent for roc is going to get FDA approval and make the whole succ versus roc debate moot?

 

[Jeff698]

Anybody know when the reversal agent for roc is going to get FDA approval and make the whole succ versus roc debate moot?

Sugammedex? For some reason I thought it was already approved and it was just my hospital that hadn't added it to the formulary.

After a quick question to Dr. Google, it seems it was approved in Europe in 2008 but rejected by the FDA in the same year.

Of course, this from the same agency that just recommended a black box warning for the most commonly prescribed meds from the ED.

It sounds like a great drug. Hopefully, it'll become available here soon.

Take care,
Jeff

 

[paiute]

if the patient is spontaneously breathing on near 100% oxygen, titrate in a little sedation (e.g. midazolam, lorazepam, propofol) , then 10 ml of 5% lidocaine squirted into the nose suddenly (stand back-pt may cough and spit); wait 2-3 minutes, then intubate with the Bullard scope; no muscle relaxant needed;

you are really burning your bridges when you use any kind of muscle relaxant; if you can't ventilate, obese people can go cyanotic in less than a minute and will die before the sux wears off;

 

[Arcan57]

It shouldn't be hard for a pharmacy to keep you well-supplied with roc. Is there are reason yours sometimes doesn't? 100mg of rocuronium will quickly provide intubating conditions as good as you're going to find anywhere, and the patient will come off of/allow reversal from 100mg of roc in much less time than 30mg of vec. I'm just curious.

I'll definitely have to look into it. The hospital has some weird rules, ie. can't use fentanyl except as part of conscious sedation and etomidate just became a drug that can only be pushed by physicians. I love that last one because I don't have enough to think about in the 20 seconds before I'm tubing someone.

 

[proman]

you are really burning your bridges when you use any kind of muscle relaxant; if you can't ventilate, obese people can go cyanotic in less than a minute and will die before the sux wears off;

This is a great comment, often disregarded. You do not have to give a muscle relaxant to intubate. However, I would argue in the setting of traumatic brain injury you must optimize your laryngoscopy, which would mean using a paralytic. With succinylcholine and rocuronium available I see no value of using high dose vecuronium.

Don't forget that hypoxia and hypercarbia are far more lethal to TBI than a transient increase in ICP. Having a patient well anesthetized prior to laryngoscopy is probably the best way to prevent the rise in ICP.