Nebulized Lidocaine

KEY POINTS:
--not a ton of evidence for use, but sounds cool, probably safe (in the appropriate non-toxic dose)
--reminder: max dose of lidocaine (without epinephrine) = 4.5mg/kg

ASTHMA/COPD:
--some benefit in daily long-term therapy for asthma, but doesn't apply to us in the ED
--lidocaine can cause bronchospasm in asthmatics, so one study pretreated with albuterol
--one study's sample dose: 1ml of 1% lido in 4 ml NS
--may be useful for cough suppression

NG TUBE PLACEMENT (in kids):
--apparently, not much proof that it helps or makes it less painful

Reference(s): asthma long-term, cough suppression, more cough suppression, ng tube, more ng tube

Lidocaine pretreatment during intubation

CONCEPT:
--intubation is associated with transient increase in BP & heart rate, due to brief catecholamine surge after messing with the larynx (probably)
--this surge can result in increased ICP, which is not great for head injury/head bleed patients
--lidocaine pretreatment can help blunt the rise in ICP

EVIDENCE:
--lidocaine shown to blunt increased ICP during endotrach suctioning, but may not directly apply to ED setting (rapid sequence intubation)
--review (linked below) "could find no evidence that in acute traumatic head injury pretreatment with IV lignocaine/lidocaine before a RSI reduces ICP or improves neurological outcome"

10-SECOND TAKEAWAY:
--RSI may cause brief increase ICP
--lidocaine pretreat (1.5mg/kg) for RSI supposed to help blunt this response
--not exactly a mountain of proof this works

QUICK TANGENT:
--fentanyl might be an alternative (1-3mcg/kg), if the BP can handle it

Reference(s): our canadian bretheren, review article, uptodate: "Pretreatment agents for rapid sequence intubation in adults"