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Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department

Published online by Cambridge University Press:  21 May 2015

Nick Kuzak ,
David W. Harrison  and
Peter J. Zed
Nick Kuzak
Affiliation:
R5 Emergency Medicine, University of British Columbia, Vancouver, BC
David W. Harrison
Affiliation:
Department of Emergency Medicine, Vancouver General Hospital, Vancouver General Hospital Hyperbaric Unit, Division of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC

Abstract

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Introduction:

Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department.

Methods:

We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) > 85 mm Hg. Contraindications to fentanyl included MAP < 85 mm Hg or allergy to fentanyl.

Results:

Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (± standard deviation) was 52.3 ± 20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%–91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%–46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of Δ 2 mcg/kg, which is the lower limit considered effective.

Conclusions:

Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.

Keywords

intubationneuroprotectionlidocainefentanyl
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 8 , Issue 2 , March 2006 , pp. 80 - 84
Copyright
Copyright © Canadian Association of Emergency Physicians 2006

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