RSI in patients with likely TBI

[PhantomShadow]

I've had a lot of TBIs coming through the Trauma Bay this month and was curious as to how everyone has approached RSI in these patients. It would be nice to quickly intubate without the need for pharmacologic therapy but these patients, as most of you know, are often clenched and require paralysis for successful intubation. An example of the regimen I like to use is (assuming 70kg patient):
Lidocaine 100mg IVP -- Succinylcholine 10mg IVP (defasiculating dose) followed by Etomidate 25mg IVP-- Succinylcholine 90mg IVP -- wait 45-60 seconds and then intubate. So, how many use Lidocaine -- what do your attendings say about its efficacy? Succinylcholine can transiently raise ICP but is the paralytic of choice at my institution if there are no contraindications. What do ya'll do?

---

Members don't see this ad.

 

[southerndoc]

It's attending-dependent whether we use lidocaine or not. Some of the studies suggest lidocaine does nothing to block the increase in ICP.

 

[NinerNiner999]

I like ketamine + sux. Be ready with suction though, things start dripping...

 

[pinbor1]

I like using vecuronium (non-depolarizing) and etomidate (quick onset and minimal change in blood pressure) for my suspected TBI. Occasionally, I'll use lidocaine if it is readily available, I'm not convinced it really dose anything.

 

[Doczilla]

I like ketamine + sux. Be ready with suction though, things start dripping...

My understanding is that ketamine is contraindicated for patients with suspected increased ICP. Etomidate is thought to be somewhat neuroprotective, though perhaps not to the extent that a barbiturate like thiopental is.

Our attendings generally reach for the etomidate and sux. Their reasoning is that sux may cause a transient spike in the ICP, but not as much as trying a "cowboy tube." The lidocaine is a +/-, some prefer to give IV, while others will spray the oropharynx in hopes of blunting the response.

Rapacurium is a nondepolarizing NMB with the onset and duration of action of succinylcholine. It's somewhere in the pipeline for FDA approval. It would be a nice compromise if it works out.


'zilla

 

[DrQuinn]

I actually had a journal club a few months ago about the use of lidocaine for intubation to decrease ICPs... really there was very little literature to support it... but the current literature is tending to show that the use of sprayed lidocaine at the posterior pharynx decreases ICPs more than placebo or IV lidocaine... I think these studies were in pediatric patients, though.

If you think about it, its really hard to come up with a study on emergent patients in the ED requiring intubation and the increase in ICP. How are you going to monitor the ICPs? Put a bolt in before you intubate?

That's why most of the studies are done either pre-operatively, or on patients in the ICU (with simulated pharyngeal stimulation -> and not the kind that Sessamoid likes to do). So they don't necessarily correlate with what we do in the ED.

BUT! AFAIK, its never been shown that IV lidocaine has detrimental effects on patients... so its not going to hurt, I suppose.

And I'd stay away from ketamine.

Q

 

[mikecwru]

You can pre-treat with lidocaine and fentanyl if you have enough time along with a defasiculating dose of a nondepolarizing agent (1/10 the normal dose) like roc, etc.

Then I use etomidate and succ.

Ketamine raises ICP and is contraindicated.

Supposedly, laryngoscopy raises ICP the same amount as putting in a foley, and we don't do all this worrying when we put in a foley. As people have stated. I think the evidence that any of this "does anything" is kind of shakey.

In my mind, the lack of an airway is more of an issue the the transient ICP rise, so that's why I use succ over roc---I do the best I can in theory with the lidocaine and fentanyl.

Neurosurgeons keep changing their opinion on the treatment of head bleeds. There's huge arguments about blood pressure control, whether or not to use mannitol, etc. So I would not worry about finding some of these issues confusing.

mike

I've had a lot of TBIs coming through the Trauma Bay this month and was curious as to how everyone has approached RSI in these patients. It would be nice to quickly intubate without the need for pharmacologic therapy but these patients, as most of you know, are often clenched and require paralysis for successful intubation. An example of the regimen I like to use is (assuming 70kg patient):
Lidocaine 100mg IVP -- Succinylcholine 10mg IVP (defasiculating dose) followed by Etomidate 25mg IVP-- Succinylcholine 90mg IVP -- wait 45-60 seconds and then intubate. So, how many use Lidocaine -- what do your attendings say about its efficacy? Succinylcholine can transiently raise ICP but is the paralytic of choice at my institution if there are no contraindications. What do ya'll do?

 

[mikecwru]

Another question is that I wonder if that dose of lidocaine along with the dilantin load that all of these people are going to get, if the mixing the two antiarrythmics potentiates dysrhytmias in the unit during the hospital course. Probably not from one dose of lidocaine.

mike

I actually had a journal club a few months ago about the use of lidocaine for intubation to decrease ICPs... really there was very little literature to support it... but the current literature is tending to show that the use of sprayed lidocaine at the posterior pharynx decreases ICPs more than placebo or IV lidocaine... I think these studies were in pediatric patients, though.

If you think about it, its really hard to come up with a study on emergent patients in the ED requiring intubation and the increase in ICP. How are you going to monitor the ICPs? Put a bolt in before you intubate?

That's why most of the studies are done either pre-operatively, or on patients in the ICU (with simulated pharyngeal stimulation -> and not the kind that Sessamoid likes to do). So they don't necessarily correlate with what we do in the ED.

BUT! AFAIK, its never been shown that IV lidocaine has detrimental effects on patients... so its not going to hurt, I suppose.

And I'd stay away from ketamine.

Q

 

[Scrubbs]

If I have the luxury of time, I actually have a rather long recipe: 100mg Lido, 100mcg Fentanyl, 1mg Vec, 20mg Etomidate, and 100mg Succ.

If the patient is crashing, I push the Lido, then the Etomidate and Succ and get an airway.

Agree... would lay off the Ketamine in TBI.

 

[roja]

Concurrance with no Ketamine. Xindicated in suspected ICP.

I tend to go for Etomidate and Succ. If I have time, I will use a defasciculating dose but often there isn't or it isn't available.

Like Quinn, we just did a huge interactive teaching module on RSI. The defasciculating dose has nothing to do with the transient, minimal increased ICP. No one really understands the mechanism but there is nothing to support its use.

 

[NinerNiner999]

Sarcasm, gentlemen, sarcasm.

 

[Jeff698]

Rapacurium is a nondepolarizing NMB with the onset and duration of action of succinylcholine. It's somewhere in the pipeline for FDA approval. It would be a nice compromise if it works out.

So I may be confused about this, but I thought rapacurium had already been approved and then withdrawn for some reason.

Perhaps I'm thinking about another drug (nondepol with sux-like profile) with a similar name...rapacuronium maybe? I remember thinking that it was a pretty cool and descriptive name.

Take care,
Jeff

 

[ERMudPhud]

Sarcasm, gentlemen, sarcasm.

Ah message board sarcasm so hard to discern.... Perhaps if you had said Ketamine plus blind nasotracheal intubation people would have gotten the point

 

[Doczilla]

Ah message board sarcasm so hard to discern.... Perhaps if you had said Ketamine plus blind nasotracheal intubation people would have gotten the point

Or just whacking them on the head like a fish you're about to clean.


Zilla D, Ninerniner N, Quinn N, et al. Preintubation thud: a randomized prospective controlled trial of standard pharmacological premedication for endotracheal intubation vs. clubbing the patient like a baby seal. Annals of SDN. 2005 May; 20(2) 415-17.


'zilla

 

[NinerNiner999]

Again, keep your suction handy...

 

[margaritaboy]

Or just whacking them on the head like a fish you're about to clean.


Zilla D, Ninerniner N, Quinn N, et al. Preintubation thud: a randomized prospective controlled trial of standard pharmacological premedication for endotracheal intubation vs. clubbing the patient like a baby seal. Annals of SDN. 2005 May; 20(2) 415-17.


'zilla

Two questions:

1. Is this a cross over trial?
2. Were there baby seals in the control group as well as the experimental group?

 

[docB]

...Succinylcholine 10mg IVP (defasiculating dose)...

Does anyone else use a defasiculating dose? I don't and none of my partners do.

 

[NinerNiner999]

I'm a big fan of simple unite dosing - one full vial per 70kg.

 

[spyderdoc]

Does anyone else use a defasiculating dose? I don't and none of my partners do.

The only time I really think about defasiculating dose is in a dialysis pt who may have a high K, and the fasiculations may push him into sine waves...

The only problem is that I usually REALLY think about it after I push the succ and see the patient defasiclate! Ooooh yeeeeah, I probably should have given that .01/kg of vec first.....

 

[docB]

The only time I really think about defasiculating dose is in a dialysis pt who may have a high K, and the fasiculations may push him into sine waves...

The only problem is that I usually REALLY think about it after I push the succ and see the patient defasiclate! Ooooh yeeeeah, I probably should have given that .01/kg of vec first.....

Yeah, I don't give it and when I do see the fasciculations I usually just think "Oh cool, it's working." If I have any suspicion of high K I use rocuronium instead of sux. As for sedation I almost always use 20 mg of etomidate. The only time I use anything else is for asthmatics and then I use ketamine. For post tube sedation I use propofol with Versed for breakthrough.

 

[drpcb]

Yeah, I don't give it and when I do see the fasciculations I usually just think "Oh cool, it's working." If I have any sutinspicion of high K I use rocuronium instead of sux. As for sedation I almost always use 20 mg of etomidate. The only time I use anything else is for asthmatics and then I use ketamine. For post tube sedation I use propofol with Versed for breakthrough.

Rocuronium 1.2-1.5mg/kg
Etomidate 0.3mg/kg
hypervent+mannitol if herniating clinically or post CT.
Dilantin ad lib

check out this weird study:

1: J Trauma. 2005 Feb;58(2):278-83.

Intracranial pressure changes during rapid sequence intubation: a swine model.

Bozeman WP, Idris AH.

Department of Emergency Medicine, Wake Forest University School of Medicine,
Winston-Salem, NC 27157, USA. [email protected]

BACKGROUND: Controversy and speculation exist regarding intracranial pressure
(ICP) changes produced by various combinations of rapid sequence intubation
(RSI) agents. In this pilot study, we sought to develop a swine model to
investigate these changes in classic RSI. METHODS: Eight adult swine were
instrumented with arterial and intracranial pressure monitors. Four different
versions of rapid sequence intubation were then performed sequentially in each
animal in a crossover trial design: regimen 1, thiopental; regimen 2, thiopental
and succinylcholine; regimen 3, lidocaine, thiopental, and succinylcholine; and
regimen 4, pancuronium, lidocaine, thiopental, and succinylcholine. ICP and
hemodynamic parameters were recorded and compared. Trials were excluded from
analysis if baseline ICP measurements were unstable or if intubation was
difficult. RESULTS: Peak changes in ICP were noted at 2 to 3 minutes after
administration of induction agents. Mean values for peak changes in ICP were as
follows: regimen 1 (n = 5), 3.6 mm Hg (95% confidence interval [CI], 1.0-6.2 mm
Hg); regimen 2 (n = 9), 13.6 mm Hg (95% CI, 9.6-17.6 mm Hg); regimen 3 (n = 2),
16.0 mm Hg (95% CI, -34.8-66.8 mm Hg); and regimen 4 (n = 3), 12.0 mm Hg (95%
CI, -8.3-32.3 mm Hg). CONCLUSION: The model is effective. It enables
investigators to examine the aggregate ICP effects of combinations of RSI
medications. RSI regimens with paralysis produced threefold increases in peak
ICP change compared with the sedation-only regimen. Pretreatment agents did not
affect ICP changes. Future investigations can examine other agents and add
experimental manipulation of ICP to simulate head injury physiology. Additional
parameters including cerebral metabolism and/or oxygenation may also be
explored.

PMID: 15706188 [PubMed - indexed for MEDLINE]

 

[docB]

Rocuronium 1.2-1.5mg/kg
Etomidate 0.3mg/kg
hypervent+mannitol if herniating clinically or post CT.
Dilantin ad lib

check out this weird study:

1: J Trauma. 2005 Feb;58(2):278-83.

Intracranial pressure changes during rapid sequence intubation: a swine model.

Bozeman WP, Idris AH.

Department of Emergency Medicine, Wake Forest University School of Medicine,
Winston-Salem, NC 27157, USA. [email protected]

PMID: 15706188 [PubMed - indexed for MEDLINE]

That's actually a cool study. Of note it's primarily a study to see if the model will work. They also excluded all difficult intubations. They note that paralysis causes more increased ICP than sedation only but other airway studies have shown that paralysis greatly increases intubation success so that you don't get into a difficult airway situation. So what's the overall effect on ICP if you do sedation only but then have a difficult intubation? Moreover it seems intuitive that your ICP jump will be worst of all if you try sedation only, fail, and then have to paralyze anyway.

 

[ERMudPhud]

Note the confidence intervals and "n's" for regimen's 3 and 4. What they are essentially saying is that for some of those trials the ICP remained unchanged or WENT DOWN. They've shown they have a model where they can measure ICP during intubation but I wouldn't draw any conclusions about which regimen to use based on this. Furthermore there was really no difference between any of the regimens that involved paralytics yet I wouldn't advocate intubating trauma patients without paralytics. The data on increased success and safety with paralytics is well established and one of the hypotheses behind the recent observations of adverse outcomes in TBI patients intubated in the field vs in the ED was the decreased use of paralytics in the field resulting in more difficult, prolonged intubations

 

[ERMudPhud]

I forgot to add that a cross over methodology is totally innappropriate here. There are all sorts of physiological responses which may become blunted after repeat stimulations. Fatiguabillity is a halmark of so many neurologic responses

 

[UTSouthwestern]

Just a couple of quick points:

Defasciculating doses of NMB's should be done with a non-depolarizer before giving sux.

Lidocaine may or may not decrease ICP, but its primary value lies in its blunting of the airway reflexes and thus prevention of coughing, gagging, etc. during laryngoscopy which can raise ICP.

Rapacuronium was withdrawn due to a number of unexplained intraoperative deaths shortly after administration of Rap. Was thought to be due to a massive release of histamine in succeptible patients.

Rocuronium will become THE RSI NMB of choice once its ultraspecific reversal/antagonist agent (cyclodextrin) is approved by the FDA. It almost instantly reverses all of the block of Roc within 10-15 seconds if necessary.

Please don't use Ketamine in this situation.

 

[12R34Y]

Just a couple of quick points:

Defasciculating doses of NMB's should be done with a non-depolarizer before giving sux.

Lidocaine may or may not decrease ICP, but its primary value lies in its blunting of the airway reflexes and thus prevention of coughing, gagging, etc. during laryngoscopy which can raise ICP.

Rapacuronium was withdrawn due to a number of unexplained intraoperative deaths shortly after administration of Rap. Was thought to be due to a massive release of histamine in succeptible patients.

Rocuronium will become THE RSI NMB of choice once its ultraspecific reversal/antagonist agent (cyclodextrin) is approved by the FDA. It almost instantly reverses all of the block of Roc within 10-15 seconds if necessary.

Please don't use Ketamine in this situation.

So, I take it there is NO consensus on this issue of giving a defasciculating dose of paralytic? UTSouthwestern says "you should" and others on this board who have been practicing for a while say "I don't".

any comments?

later

 

[roja]

Ever heard the phrase that trying to get doctors to agree on anything is kind of like trying to herd cats?

 

[Doczilla]

Ever heard the phrase that trying to get doctors to agree on anything is kind of like trying to herd cats?

Or like trying to paint a picture with a bunch of colored mice.

 

[UTSouthwestern]

So, I take it there is NO consensus on this issue of giving a defasciculating dose of paralytic? UTSouthwestern says "you should" and others on this board who have been practicing for a while say "I don't".

any comments?

later

You should use a defasciculating dose if you feel you absolutely have to use a depolarizer like sux. Hopefully that isn't the majority of the time. Sux can at least transiently raise your ICP directly or indirectly. If you have any doubts about the airway, have an LMA and fiberoptic scope available and be prepared to cric as needed.

 

[12R34Y]

Ever heard the phrase that trying to get doctors to agree on anything is kind of like trying to herd cats?

nuff said.

later