Prehospital sedation

[Arizonaffcep]

Additionally, I would like to emphasize that yes etomidate is well known to cause transient adrenal suppression after one dose. However, I am unaware of any evidence that definitively says etomidate leads to poor outcomes in patients where this may be a problem. There are studies and allot of talk; however, the fact remains that etomidate is still a viable agent...

Take care,

chbare.

CH, from the research I've done in the past year (first partner on the helicopter was really into this etomidate stuff) it's not a single does that does the bad, as levels will return to normal and if you look at the output for 24 hours, there is little difference between those that didn't get it and those that got a single dose. However, the continued use (ie etomidate drip) is what all the commotion is about. I would quote the studies, but taking a break from chart writing and don't have the time to re-research them.

[fireflymedic]

LOUD NOISES!!!!

[chbare]

CH, from the research I've done in the past year (first partner on the helicopter was really into this etomidate stuff) it's not a single does that does the bad, as levels will return to normal and if you look at the output for 24 hours, there is little difference between those that didn't get it and those that got a single dose. However, the continued use (ie etomidate drip) is what all the commotion is about. I would quote the studies, but taking a break from chart writing and don't have the time to re-research them.

As I stated, there is no smoking gun against etomidate (Single dose for RSI) as far as the literature is concerned IMO. However, the theoretical pitfalls of etomidate are causing some commotion. This is especially true in the setting of patients who are at increased risk such as a patient in septic shock. Unfortunately, these conditions are associated with high levels of morbidity and mortality and I suspect making a clear correlation will be difficult, if one does in fact exist. I do not think the last word has been spoken on this issue especially in light of an aggressive surviving sepsis campaign.

Taie care,

chbare.

[DartmouthDave]

Hello,

We tend to give IV steroids if Etomidate has been given.

As for the pro and cons I am not sure what to think.

Up To Date (lit review was 09/2009) states this:

Adrenocortical suppression — The major controversy surrounding etomidate stems from the reversible adrenocortical suppression associated with its use [26-29]. Etomidate is a reversible inhibitor of 11-beta-hydroxylase, which converts 11-deoxycortisol to cortisol (algorithm 1). (See "Adrenal steroid biosynthesis".)

A single dose of etomidate causes a measurable decrease in the level of circulating cortisol that occurs in response to the administration of exogenous ACTH, although cortisol levels do not fall below the normal physiologic range. The effect does not persist beyond 12 to 24 hours [29].

Some researchers have raised concerns regarding the safety of etomidate in the setting of adrenal insufficiency related to sepsis [27,28,30]. However, no well-designed, prospective trial has shown adverse effects from a single dose of etomidate used for intubation in patients with sepsis or septic shock.

A multicenter randomized trial of critically ill patients requiring emergent intubation found no difference in organ failure score, 28 day mortality, or intubating conditions between patients given etomidate for induction and those given ketamine [31]. No serious, drug-related adverse events were reported for either medication. Although adrenal insufficiency occurred at a higher rate in the etomidate group (86 percent), it also developed in approximately 48 percent of patients receiving ketamine.

Other retrospective studies and small randomized trials have shown mixed results that also do not support recommendations to avoid using etomidate for induction in patients with sepsis.

However, I read in Trauma (...I think this study was metioned in a JEMS magazine as well...I will look into this....at work again) that Etomidate caused higher mortality rate. As well STARS (Alberta) recently withdrew Etomidate from thier drugs box after concerns were raised local Intensivists.

Cheers

David

[HellsBells]

Do you see Etomindate or ketamine prehospitally in your area?

I agree btw. Why these agents are not in use round here, is beyond me.

We have Etomidate on our trucks Mobey. However, protocols state it is to be used only in hypotensive pts who are in the 70-90 systolic range.