--- title: "Most Missed Question Pediatric EM: RSI Meds in Suspected Increased ICP" description: "Neuro-RSI in a child with suspected increased ICP: why etomidate + rocuronium is the exam-safe choice and why lidocaine pretreatment is outdated." image: https://challengercme.com/hubfs/Blog%20Covers/Blog%20-%20Most%20Missed%20Question%20Pediatric%20EM_%20RSI%20Meds%20in%20Suspected%20Increased%20ICP.png --- [![Med-Challenger-green-logo-1024x244](https://challengercme.com/hubfs/Med-Challenger-green-logo-1024x244.webp) ](https://challengercme.com/) - [SHOP EXAM PREP & CME ](https://challengercme.com/blog/most-missed-question-pediatric-em-rsi-meds-in-suspected-increased-icp#) ### [EMERGENCY MEDICINE](https://challengercme.com/emergency-medicine-exam-review-cme-course) [ABEM exam prep](https://challengercme.com/emergency-medicine-exam-review-cme-course), [MyEMCert](https://challengercme.com/emergency-medicine-myemcert-exam-review-course), etc. ### [FAMILY MEDICINE](https://challengercme.com/family-medicine-exam-review-cme-course) [ABFM exam prep](https://challengercme.com/family-medicine-exam-review-cme-course), [ABFM KSA](https://challengercme.com/family-medicine-moc-ksa-course), etc. ### [INTERNAL MEDICINE ABIM exam prep, MOC points, etc.](https://challengercme.com/internal-medicine-exam-review-cme-course) ### [OBGYN ABOG exam prep, CREOG, etc.](https://challengercme.com/obgyn-exam-review-cme-course) ### [PEDIATRICS ABP exam prep, MOCA-PEDS, etc.](https://challengercme.com/pediatric-medicine-exam-review-cme-course) ### [PEDIATRIC EM](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [ABP/ABEM exam prep Ed.3](https://challengercme.com/pediatric-emergency-medicine-3rd-edition), [Ed.2](https://challengercme.com/pediatric-emergency-medicine-pack2), etc. ### [SPECIAL PURPOSE / SPEX FSMB exam prep, etc.](https://challengercme.com/special-purpose-exam-review-spex-exam-preparation-course) ### [PHYSICIAN ASSISTANT](https://challengercme.com/physician-assistant-exam-review-cme-course) [PANCE / PANRE](https://challengercme.com/physician-assistant-exam-review-cme-course), [CAQ-EM](https://challengercme.com/pa-caq-em-review-course), etc ### [NURSE PRACTITIONER](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course) [FNP](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course), [ENP](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course), [AGNP](https://challengercme.com/adult-gerontology-nurse-practitioner-exam-review-cne-course), [PNCB/CPNP](https://challengercme.com/pediatric-nurse-practitioner-exam-review-cne-course), etc. ### [NURSING / NCLEX NCLEX, CNE, etc.](https://challengercme.com/nursing-certification-nclex-exam-review-cne-courses) ### [STATE-REQUIRED CME / CE State CME requirements, etc.](https://challengercme.com/state-required-cme) ### [JOINT COMMISSION CME](https://challengercme.com/stroke-center-ce-review-course) [Stroke](https://challengercme.com/stroke-center-ce-review-course), [Cardiac](https://challengercme.com/cardiac-center-ce-review-course), [Trauma](https://challengercme.com/trauma-center-ce-review-course), [ALS](https://challengercme.com/advanced-life-support-and-resuscitation-center-ce-review-course), etc. ### [PROFESSIONALISM CME Professionalism review with CME](https://challengercme.com/professionalism-review-course) ### [DERMATOLOGY CME Dermatology review with CME](https://challengercme.com/dermatology-review-course) ### [USMLE STEP 2CK / STEP 3 USMLE exam prep, etc.](https://challengercme.com/usmle-certification-exam-review-clerkship-exams-shelf-exam-review) - [INSTITUTIONS ](https://challengercme.com/atlas-pro-inst) - [BLOG ](https://challengercme.com/blog) - [SUPPORT ](https://support.challengercme.com/knowledge) [SIGN IN ](https://fuse.challengercme.com/sign-in?redirectURL=%2Fuserdash) pediatric emergency medicine # Most Missed Question Pediatric EM: RSI Meds in Suspected Increased ICP Neuro-RSI in a child with suspected increased ICP: why etomidate + rocuronium is the exam-safe choice and why lidocaine pretreatment is outdated. [ Challenger Corporation ](https://challengercme.com/blog/author/challenger-corporation) Dec 31, 2025 [Commonly Missed Questions](https://challengercme.com/blog/tag/commonly-missed-questions) [pediatric emergency medicine](https://challengercme.com/blog/tag/pediatric-emergency-medicine) ### < [All Posts](https://challengercme.com/blog) Exam Prep + CME Med-Challenger Peds EM Pass-guaranteed PEDS EM exam review with CME built-in. Try it for free. [START PEDS EM REVIEW](https://fuse.challengercme.com/fulltrial/233) --- ### Share this article [mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-pediatric-em-rsi-meds-in-suspected-increased-icp&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-pediatric-em-rsi-meds-in-suspected-increased-icp&utm_medium=social&utm_source=email](mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-pediatric-em-rsi-meds-in-suspected-increased-icp&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-pediatric-em-rsi-meds-in-suspected-increased-icp&utm_medium=social&utm_source=email) ### Subscribe ### Subscribe ![RSI Meds in Suspected Increased ICP](https://challengercme.com/hubfs/Blog%20Covers/Blog%20-%20Most%20Missed%20Question%20Pediatric%20EM_%20RSI%20Meds%20in%20Suspected%20Increased%20ICP.png) 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. [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLtvEkTlykIV5FE7t2exICkE5JqQIaQKdCShOesDDoJAUVJry1sQVyjJxN9Qxpqetz%2BVG%2BTc3M7N7gIEgememsfll24biDX4Kat%2BLnLW6EMUnm3aGXC%2BtziIav2%2BPYp0btAhZVmGe5u94tcQ76MwSk%2FGe5D5tbUT2QSMZAInNFa5Co5nCvSCsRW%2F2GrDg%3D%3D&webInteractiveContentId=194510541423&portalId=9106197)   ## **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 rocuronium   B. 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. [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLtvEkTlykIV5FE7t2exICkE5JqQIaQKdCShOesDDoJAUVJry1sQVyjJxN9Qxpqetz%2BVG%2BTc3M7N7gIEgememsfll24biDX4Kat%2BLnLW6EMUnm3aGXC%2BtziIav2%2BPYp0btAhZVmGe5u94tcQ76MwSk%2FGe5D5tbUT2QSMZAInNFa5Co5nCvSCsRW%2F2GrDg%3D%3D&webInteractiveContentId=194510541423&portalId=9106197) ## 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   Answer and Remediation A — Review: Lidocaine pretreatment not routinely recommended; succinylcholine not necessary here and has specific contraindications.   B — Correct response!: Hemodynamically stable induction + rapid paralysis; facilitates ventilation control (AHA PALS 2020 hemodynamic priorities).   C — Review: Propofol may cause hypotension and reduce CPP in suspected elevated ICP.   D — Review: Without paralysis this is not RSI and risks failed conditions for airway control.   E — Review: Missing an induction agent; lidocaine alone is not sufficient and not routinely supported. ### **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   Answer and Remediation A — Review: Propofol commonly worsens hypotension.   B — Correct response!: Ketamine supports blood pressure and is acceptable in neuro patients when ventilation is controlled (modern consensus; avoid hypotension per resuscitation principles).   C — Review: Lidocaine pretreatment does not address shock and lacks outcome benefit.   D — Review: Etomidate is reasonable but ketamine is often preferred when hypotension is present.   E — Review: Inhumane/unsafe; induction is still needed unless truly peri-arrest with no time. ### **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   Answer and Remediation A — Review: Historic practice; not routinely recommended based on current evidence.   B — Correct response!: This reflects current exam-consensus: insufficient high-quality evidence for routine benefit.   C — Review: Modern data do not show consistent ICP increase when ventilation is controlled.   D — Review: Rocuronium is commonly used; key is ongoing sedation/analgesia. E — Review: Paralysis does not provide sedation or amnesia. ### **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%   Answer and Remediation A — Review: Hypercapnia can raise ICP via cerebral vasodilation.   B — Correct response!: Prevent secondary brain injury; preserving cerebral perfusion is critical (aligned with resuscitation principles in AHA PALS 2020).   C — Review: Excess hypertension isn’t a goal; avoid extremes.   D — Review: Airway/ventilation take priority; paralysis is often needed for safe RSI.   E — Review: Aim for normal oxygenation; avoid hypoxemia. ### **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   Answer and Remediation A — Review: Paralysis without sedation is unacceptable and dangerous.   B — Correct response!: Standard RSI uses both induction and paralysis for optimal intubating conditions and patient safety.   C — Review: Lidocaine is not an induction agent and not adequate for RSI.   D — Review: Without paralytic, intubating conditions may be poor; propofol may cause hypotension.   E — Review: “Awake paralysis” is not acceptable practice. ## **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](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [Try for free and save](https://fuse.challengercme.com/fulltrial/233). Ace your exams and meet your CME/MOC requirements. 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