A 20yo M is BIBEMS after falling from a scaffold at a construction site.  He has signs of head trauma.

Upon arrival his VS are:

T=98.9 HR=75 BP=185/90 RR=12 o2 Sat=99% on NRB

His neuro exam:

PERRL, moving all extremities

eyes open to pain

making incomprehensible sounds

painful stimulation to the nail bed on the right hand causes him to withdrawal.

Calculate his GCS.


After calculating his GCS (8), you decide he likely has severe TBI and needs to be intubated.

Using a neuro-protective approach, what two medications would you use to pre-medicate?  what is the order, dosage and timing prior to induction?

What is the induction medication of choice for this patient?  Would your choice change if he is hypo or normotensive?

Although the evidence is not strong, minimize increase in ICP with:
1) lidocaine (1.5mg/kg) IVP 3 minutes prior to induction
2) fentanyl (3mcg/kg) slow IVP 3 minutes prior to induction, after lidocaine.  Reduce to 1mcg/kg if pt is hemodynamically unstable.

Induction agents
1. Etomidate 0.3mg/kg IVP, if hypertensive
2. Ketamine 1-2mg/kg IVP, use if hypotensive or normotensive

(limited evidence that it causes increased ICP, however, avoid if patient is already hypertensive)


Grover VK, Reddy GM, Kak VK, Singh S. Interacranial pressure changes with different doses of lignocaine under general anaesthesia. Neurol India. 1999;47(2):118.

Kerr ME, Sereika SM, Orndoff P, Weber B, Rudy EB, Marion D, Stone K, Turner B. Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries. Am J Crit Care. 1998;7(3):205.

Bourgoin A, Albanèse J, Léone M, Sampol-Manos E, Viviand X, Martin C. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med. 2005;33(5):1109.