Intubating a patient with a suspected head bleed is one of the highest risk situations we encounter as ED physicians. A failed attempt with enough airway manipulation can potentially increase ICP and have profound negative effects on patient outcomes. EM dogma, perhaps antiquated, dictates pretreatment with an opiate, typically fentayl, and lidocaine. But is the lidocaine necessary…

The theory:

  • In the cardiac literature, researchers observed a reduced ICP in those treated with lidocaine during management of their cardiac dysrhythmias, by reducing cerebral blood volume, lowering cerebral vascular resistance, and decreasing cerebral metabolism as well as suppressing the cough reflex.

The evidence:

  • One study of 30 patients undergoing elective VP shunt placement found a significant drop in ICP following doses of 1.5 and 2 mg/kg of lidocaine prior to their procedure. A second study of 15 comatose ICU patients with diffuse brain injuries found a 4-6 mmHg decrease in ICP following lidocaine administration

The counter argument:

  • In two prospective randomized trials of neurosurgical patients under going endotracheal intubation, one including 124 patients and the other including 22 patients demonstrated no significant decrease in ICP or attenuation in rise in ICP caused by intubation. Similar results were seen in a third trial looking at ICP increases during endotracheal suctioning.

The take home:

  • There is no good evidence to support the routine pretreatment of patients with possible increased ICP with lidocaine prior to intubation.



Bachofen, M M. Suppression of blood pressure increases during intubation: lidocaine or fentanyl?. Der Anaesthesist (0003-2417), 37 (3), p. 156.

Caro, D. Pretreatment agents for rapid sequence intubation in adults. Uptodate. Walls, RM. Grayzel, J (EDs).

Grover V K, Reddy G M, Kak V K, Singh S. Intracranial pressure changes with different doses of lignocaine under general anaesthesia. Neurol India 1999;47:118

Samaha T, Ravussin P, Claquin C, Ecoffey C. Prevention of increase of blood pressure and intracranial pressure during endotracheal intubation in neurosurgery: esmolol versus lidocaine. Ann Fr Anesth Reanim. 1996;15(1):36.

White PF, Schlobohm RM, Pitts LH, Lindauer JM. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology. 1982;57(3):242.

July 2024