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EMSWORLD.com | MARCH 2015 39 This position was followed by a 2006 case report and letter in the Journal of Emergency Medicine from three physicians in London. In their letter, these physicians reported another case of an NPA in the cranium following severe facial trauma in a patient whose airway could otherwise not be managed due to a clenched jaw. The authors agreed the placement of an NPA into the cranium is exceedingly rare and most likely results from poor placement techniques. It was their opinion that airway management should take precedence over the risk of an extremely rare consequence. 2 Further, NPA placement is recom- mended for military prehospital providers even in the case of head injury. David Steinbruner, MD, et al., identified that the military position is that proper placement of the NPA to establish a patent airway offers significantly greater benefit from improved airway management than the relatively small risk the NPA may penetrate the skull. 3 Multiple different sources support the use of proper nasal airway placement for patients with head inju- ries; the key here being using proper technique and stopping when resistance is met and directing the airway along the base of the naval cavity as shown in Figure 1a. Directing any nasally placed device upward toward the eyes increases the likelihood of complica- tions. Keep in mind, these papers are encouraging the use of nasopharyngeal airways and not nasal intubation or nasogastric tubes in head injury. Both of these latter devices are more rigid than the NPA and nasogastric tubes in particular may have a greater likelihood of compromising the basilar skull. The Bottom Line Nasopharyngeal airway placement can safely be performed in patients with head injury when airway management is needed. The benefit of establishing an airway outweighs the incredibly small risk of the NPA entering the brain. Myth #2: Lidocaine in RSI Prevents Increased ICP in the Head-Injured Patient The myth explained: It is known that laryngeal manipulation and endotracheal intubation are both associated with a transient rise in intracranial pres- sure (ICP), and patients who have a head injury with increased ICP are considered at an increased risk for secondary brain injury. Since a transient ICP rise could decrease cerebral perfusion pressures, every effort is made to control ICP. In theory, lido- caine prevents this transient ICP rise, which helps prevent a secondary brain injury. Evidence for lido- caine as a preventive measure first appeared in 1980, when Robert Bedford, et al., published their paper, "Lidocaine prevents increased ICP after endotracheal intubation," when they monitored 20 patients who were undergoing elective neurosurgery. Their results showed that while patients who received lidocaine did experience a rise in ICP, it was significantly less than in patients who received a placebo. Ultimately, these results were extrapolated to use lidocaine as part of the medication sequence for intubation, although this study did not address this question at all. The Evidence Drs. Mike Clancy and Neil Robinson reviewed all of the available literature regarding the use of lidocaine in RSI and published their findings in 2001. After an exhaustive literature review, they only found six papers that addressed lidocaine and intracranial pres- sure changes. No paper studied lidocaine during RSI. These authors concluded there is no evidence to sup- port the use of lidocaine as a clinical intervention during RSI and recommended its administration be limited to clinical trials. 4 Although there is no evidence to support the use of lidocaine, is there evidence that suggests that lido- caine causes harm? A 2012 paper in the American Journal of Emergency Medicine determined lido- Figure 1a: Proper NPA insertion technique directs the airway toward the posterior pharynx. Figure 1b: Improper NPA insertion technique directs the airway towards the skull. Photos by Kevin Collopy ABOUT THE AUTHORS Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is clinical education coordinator for VitaLink/AirLink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail ktcollopy@gmail.com. Sean M. Kivlehan, MD, MPH, NREMT-P, is an emer- gency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail. com. Scott R. Snyder, BS, NREMT-P, is full- time faculty at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. He is also a paramedic with AMR: Sonoma Life Support in Santa Rosa, CA. E-mail scottrsnyder@ me.com.