The board-reliable approach to intubating a child with suspected increased ICP is to prioritize oxygenation/ventilation and avoid hypotension, using an induction agent with minimal hemodynamic impact.
Question – RSI meds
A 9 yo boy with history of a pontine glioma and shunted hydrocephalus presents with concern for frequent vomiting. Initial vital signs upon arrival to the ED T 36.8°C HR 75, RR 18, O2 98%, BP 116/68. Neurological exam reveals right sided weakness, right facial hemiparesis, and an ataxic gait consistent with his baseline. After administration of an NS bolus and IV Zofran he develops right sided tonic-clonic seizure activity and diminished respiratory effort. Repeat vital signs Temp 36.8°C HR 62, RR 10, O2 92%, BP 136/88. Which of the following medications would be most appropriate for intubation?
Answer Options:
A. IV Etomidate and rocuroniumB. IV Ketamine and rocuronium
C. IV Lidocaine and propofol
D. IV Lidocaine and rocuronium
Validated answer: A. IV Etomidate and rocuronium. The keyed answer is acceptable and consistent with contemporary neuro-airway priorities (avoid hypotension; minimize hemodynamic swings).
The item is frequently missed because many clinicians were taught older dogma: (1) lidocaine “pretreatment” to blunt ICP rise with laryngoscopy, and (2) avoiding ketamine in elevated ICP. Current evidence does not support routine lidocaine pretreatment to improve clinically meaningful outcomes, and ketamine is generally considered safe in neurologic illness when ventilation is controlled. On exams, however, etomidate remains the most “hemodynamically neutral” induction agent and is a conservative, testable choice for suspected elevated ICP—particularly when you want to avoid hypotension and also avoid a large sympathetic surge.
Guideline framing: while pediatric resuscitation guidance (AHA PALS 2020) is not an “RSI drug guideline,” it consistently emphasizes preventing hypoxemia/hypoventilation and avoiding hypotension in critically ill children. In a neuro-compromised patient, that principle maps to choosing induction/RSI medications with predictable hemodynamics and rapid onset.
Why This Pediatric Emergency Medicine Question Is Often Missed
- Older teaching overemphasizes lidocaine pretreatment for “neuroprotection,” despite limited evidence for benefit.
- Persistent myth that ketamine increases ICP in all cases; modern data do not support this when ventilation is controlled.
- Test-takers focus on the BP (136/88) and forget the bigger priority: secure the airway without causing hypotension or worsening ventilation/CO₂.
What the Distractors Indicate
| Option | What It Tests / Implies | Why It’s Wrong Here |
| IV Etomidate and rocuronium | Hemodynamic neutrality + rapid paralysis for RSI | Best exam-reliable choice for suspected elevated ICP when you want minimal BP change and rapid control of ventilation. |
| IV Ketamine and rocuronium | Ketamine safety in neuro patients; preserves BP | Ketamine is *reasonable/acceptable*, but not clearly “more appropriate” than etomidate in this vignette; the question is aiming for the classic hemodynamically neutral neuro-RSI choice. |
| IV Lidocaine and propofol | “Blunt ICP rise” + deep sedation | Propofol can cause hypotension (bad for cerebral perfusion), and lidocaine pretreatment lacks strong outcome evidence; also missing a paralytic for RSI. |
| IV Lidocaine and rocuronium | Lidocaine pretreatment + paralysis | Lidocaine is not recommended as routine pretreatment; also lacks an induction sedative/hypnotic agent. |
High-Yield Pearl for Exam Prep
In suspected elevated ICP, pick an RSI strategy that avoids hypotension and allows rapid control of ventilation/CO₂; etomidate + rocuronium is the conservative exam answer.
Core Learning Objectives
1. Choose RSI medications for pediatric patients with suspected increased intracranial pressure emphasizing hemodynamic stability and rapid control of ventilation.2. Recognize that lidocaine pretreatment is not routinely supported and that ketamine is generally acceptable in neurologic illness when ventilation is controlled.
The Exam “Test Trick” at Play
The stem tempts you to reach for “neuroprotective pretreatment” (lidocaine) or to reject ketamine due to outdated ICP concerns. Boards more often reward the simplest, highest-signal approach: secure the airway with a standard induction agent that doesn’t drop BP (etomidate) plus a reliable paralytic (rocuronium), then manage ventilation and ongoing seizure activity.
Additional Peds EM Practice Questions and Remediation for RSI in Elevated ICP
Pediatric Emergency Medicine Practice Question 1 — Postictal hypoventilation
A 7-year-old with ventriculoperitoneal shunt presents with headache/vomiting and becomes apneic after a generalized seizure. BP is normal. Best RSI induction/paralysis pair?
A. Lidocaine + succinylcholine
B. Etomidate + rocuronium
C. Propofol + rocuronium
D. Midazolam + no paralytic
E. Lidocaine + rocuronium
Pediatric Emergency Medicine Practice Question 2 - Hypotensive head injury
A 10-year-old with severe TBI is hypotensive (SBP 70) and needs emergent intubation. Best induction agent concept?
A. High-dose propofol
B. Ketamine
C. Lidocaine pretreatment
D. Etomidate in all cases
E. No induction agent
Pediatric Emergency Medicine Practice Question 3 - “Pretreatment” myth
During RSI planning for suspected elevated ICP, which statement is best?
A. Lidocaine must be given 3 minutes prior to laryngoscopy
B. Routine lidocaine pretreatment is not supported by strong evidence for outcome benefit
C. Ketamine is contraindicated in all intracranial pathology
D. Rocuronium is contraindicated in neuro patients
E. Paralysis eliminates need for sedation
Pediatric Emergency Medicine Practice Question 4 - Avoiding secondary brain injury
A 9-year-old with brain tumor needs intubation for declining mental status. Which peri-intubation physiologic target is most important?
A. Mild hypercapnia (PaCO₂ 55–60)
B. Avoid hypotension
C. Induce significant hypertension
D. Avoid paralysis to preserve neuro exam
E. Maintain SpO₂ 90–92%
Pediatric Emergency Medicine Practice Question 5 - Sedation + paralysis pairing
Which RSI medication plan is most appropriate in a child requiring immediate airway control?
A. Rocuronium alone
B. Induction sedative + paralytic (e.g., etomidate + rocuronium)
C. Lidocaine alone
D. Propofol alone without paralytic
E. Paralytic first, sedative later if needed
Mini Case Discussion Prompt
How would your RSI medication selection change if this same patient were (a) profoundly hypotensive, (b) bradycardic with signs of herniation, or (c) actively in status epilepticus requiring ongoing anticonvulsant infusions post-intubation?
Mini-FAQ
Q1: Is ketamine contraindicated in suspected increased ICP?
A: No. The ABIM/board-style expectation is that ketamine is generally acceptable in neurologic illness when ventilation is controlled; avoid hypoventilation/hypercapnia and hypotension.
Q2: Should I routinely give lidocaine before RSI in neuro patients?
A: No. Routine lidocaine “pretreatment” lacks strong outcome evidence; exams increasingly favor focusing on physiologic goals (oxygenation, ventilation, hemodynamic stability).
Q3: Why is etomidate a common exam answer for neuro-RSI?
A: Because it is classically considered hemodynamically neutral, aligning with the testable priority to avoid peri-intubation hypotension and secondary brain injury.
Q4: What is the most important post-intubation step in suspected elevated ICP?
A: Ensure controlled ventilation/oxygenation and adequate ongoing sedation/analgesia while avoiding hypotension—boards test prevention of secondary brain injury.
Find this and other Pediatric Emergency Medicine exam prep questions in Med-Challenger Pediatric Emergency Medicine 3rd Edition Exam Review with CME
Try for free and save. Ace your exams and meet your CME/MOC requirements.
No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.
