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Emergency airway management in the patient with elevated ICP

Andy Jagoda, MD
Section Editor
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Patients with acute elevations in intracranial pressure (ICP) from trauma, stroke, infection of the central nervous system, or other processes often require emergent airway management. In managing these patients, certain medications and techniques reduce the likelihood of major fluctuations in cerebral perfusion pressure, which can exacerbate brain injury.

This topic will discuss emergent airway management in patients with elevated ICP. Other aspects of emergent airway management and diseases that cause elevations in ICP are reviewed separately.

For further discussion of emergent airway management: (see "Basic airway management in adults" and "Advanced emergency airway management in adults" and "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach").

For discussions of injuries and diseases that elevate ICP: (see "Evaluation and management of elevated intracranial pressure in adults" and "Skull fractures in adults" and "Management of acute severe traumatic brain injury" and "Overview of the evaluation of stroke" and "Management of vasogenic edema in patients with primary and metastatic brain tumors" and "Severe traumatic brain injury in children: Initial evaluation and management").


Cerebral perfusion pressure (CPP) is the driving force for blood flow to the brain. It is calculated by taking the difference between the mean arterial blood pressure (MAP) and the intracranial pressure (ICP), as expressed in the formula CPP = MAP – ICP. The pathophysiology of elevated ICP is discussed in detail separately; issues of particular relevance to airway management are highlighted below. (See "Evaluation and management of elevated intracranial pressure in adults" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis".)

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Literature review current through: Oct 2017. | This topic last updated: Sep 14, 2017.
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  1. Perkins ZB, Wittenberg MD, Nevin D, et al. The relationship between head injury severity and hemodynamic response to tracheal intubation. J Trauma Acute Care Surg 2013; 74:1074.
  2. Muller MD, Mast JL, Cui J, et al. Tactile stimulation of the oropharynx elicits sympathoexcitation in conscious humans. J Appl Physiol (1985) 2013; 115:71.
  3. Kayhan Z, Aldemir D, Mutlu H, Oğüş E. Which is responsible for the haemodynamic response due to laryngoscopy and endotracheal intubation? Catecholamines, vasopressin or angiotensin? Eur J Anaesthesiol 2005; 22:780.
  4. Takahashi S, Mizutani T, Miyabe M, Toyooka H. Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device (Trachlight) in adults with normal airway. Anesth Analg 2002; 95:480.
  5. Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987; 59:295.
  6. Stoelting RK. Circulatory changes during direct laryngoscopy and tracheal intubation: influence of duration of laryngoscopy with or without prior lidocaine. Anesthesiology 1977; 47:381.
  7. Tewari P, Gupta D, Kumar A, Singh U. Opioid sparing during endotracheal intubation using McCoy laryngoscope in neurosurgical patients: the comparison of haemodynamic changes with Macintosh blade in a randomized trial. J Postgrad Med 2005; 51:260.
  8. Barak M, Ziser A, Greenberg A, et al. Hemodynamic and catecholamine response to tracheal intubation: direct laryngoscopy compared with fiberoptic intubation. J Clin Anesth 2003; 15:132.
  9. Tong JL, Ashworth DR, Smith JE. Cardiovascular responses following laryngoscope assisted, fibreoptic orotracheal intubation. Anaesthesia 2005; 60:754.
  10. Moorthy SS, Greenspan CD, Dierdorf SF, Hillier SC. Increased cerebral and decreased femoral artery blood flow velocities during direct laryngoscopy and tracheal intubation. Anesth Analg 1994; 78:1144.
  11. Chraemmer-Jørgensen B, Høilund-Carlsen PF, Marving J, Christensen V. Lack of effect of intravenous lidocaine on hemodynamic responses to rapid sequence induction of general anesthesia: a double-blind controlled clinical trial. Anesth Analg 1986; 65:1037.
  12. Moulton C, Pennycook AG. Relation between Glasgow coma score and cough reflex. Lancet 1994; 343:1261.
  13. Chung KS, Sinatra RS, Halevy JD, et al. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth 1992; 39:774.
  14. Cork RC, Weiss JL, Hameroff SR, Bentley J. Fentanyl preloading for rapid-sequence induction of anesthesia. Anesth Analg 1984; 63:60.
  15. Dahlgren N, Messeter K. Treatment of stress response to laryngoscopy and intubation with fentanyl. Anaesthesia 1981; 36:1022.
  16. Splinter WM, Cervenko F. Haemodynamic responses to laryngoscopy and tracheal intubation in geriatric patients: effects of fentanyl, lidocaine and thiopentone. Can J Anaesth 1989; 36:370.
  17. Hussain AM, Sultan ST. Efficacy of fentanyl and esmolol in the prevention of haemodynamic response to laryngoscopy and endotracheal intubation. J Coll Physicians Surg Pak 2005; 15:454.
  18. Adachi YU, Satomoto M, Higuchi H, Watanabe K. Fentanyl attenuates the hemodynamic response to endotracheal intubation more than the response to laryngoscopy. Anesth Analg 2002; 95:233.
  19. del Río Vellosillo M, Gallego García J, Soliveres Ripoll J, et al. [Bolus administration of fentanyl vs continuous perfusion of remifentanil for control of hemodynamic response to laryngoscopy and orotracheal intubation: a randomized double-blind trial]. Rev Esp Anestesiol Reanim 2009; 56:287.
  20. Payne KA, Murray WB, Oosthuizen JH. Obtunding the sympathetic response to intubation. Experience at 2 minutes after administration of the test agent in patients with cerebral aneurysms. S Afr Med J 1988; 73:584.
  21. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J 2001; 18:453.
  22. Butler J, Jackson R. Towards evidence based emergency medicine: best BETs from Manchester Royal Infirmary. Lignocaine premedication before rapid sequence induction in head injuries. Emerg Med J 2002; 19:554.
  23. Helfman SM, Gold MI, DeLisser EA, Herrington CA. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol? Anesth Analg 1991; 72:482.
  24. Abou-Madi MN, Keszler H, Yacoub JM. Cardiovascular reactions to laryngoscopy and tracheal intubation following small and large intravenous doses of lidocaine. Can Anaesth Soc J 1977; 24:12.
  25. Bachofen M. [Suppression of blood pressure increases during intubation: lidocaine or fentanyl?]. Anaesthesist 1988; 37:156.
  26. Grover VK, Reddy GM, Kak VK, Singh S. Intracranial pressure changes with different doses of lignocaine under general anaesthesia. Neurol India 1999; 47:118.
  27. White PF, Schlobohm RM, Pitts LH, Lindauer JM. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology 1982; 57:242.
  28. Donegan MF, Bedford RF. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology 1980; 52:516.
  29. Bilotta F, Branca G, Lam A, et al. Endotracheal lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics in patients with severe head trauma. Neurocrit Care 2008; 8:241.
  30. 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; 15:36.
  31. Yano M, Nishiyama H, Yokota H, et al. Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 1986; 64:651.
  32. Raymondos K, Münte S, Krauss T, et al. Cortical activity assessed by Narcotrend in relation to haemodynamic responses to tracheal intubation at different stages of cortical suppression and reflex control. Eur J Anaesthesiol 2003; 20:44.
  33. Oda Y, Nishikawa K, Hase I, Asada A. The short-acting beta1-adrenoceptor antagonists esmolol and landiolol suppress the bispectral index response to tracheal intubation during sevoflurane anesthesia. Anesth Analg 2005; 100:733.
  34. Feng CK, Chan KH, Liu KN, et al. A comparison of lidocaine, fentanyl, and esmolol for attenuation of cardiovascular response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Sin 1996; 34:61.
  35. Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J 2001; 18:373.
  36. Moss E, Powell D, Gibson RM, McDowall DG. Effect of etomidate on intracranial pressure and cerebral perfusion pressure. Br J Anaesth 1979; 51:347.
  37. Modica PA, Tempelhoff R. Intracranial pressure during induction of anaesthesia and tracheal intubation with etomidate-induced EEG burst suppression. Can J Anaesth 1992; 39:236.
  38. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34:216.
  39. May N, Anderson K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: Suxamethonium (succinylcholine) for RSI and intubation in head injury. Emerg Med J 2012; 29:511.
  40. Lanier WL, Iaizzo PA, Milde JH. Cerebral function and muscle afferent activity following intravenous succinylcholine in dogs anesthetized with halothane: the effects of pretreatment with a defasciculating dose of pancuronium. Anesthesiology 1989; 71:87.
  41. Cottrell JE, Hartung J, Giffin JP, Shwiry B. Intracranial and hemodynamic changes after succinylcholine administration in cats. Anesth Analg 1983; 62:1006.
  42. Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg 1994; 78:469.
  43. Sun HL, Wu TJ, Ng CC, et al. Efficacy of oropharyngeal lidocaine instillation on hemodynamic responses to orotracheal intubation. J Clin Anesth 2009; 21:103.
  44. Warner KJ, Cuschieri J, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma 2007; 62:1330.
  45. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80:6.