Etomidate

[Paramagic]

The idea of ambo's being let loose with etomidate/propofol scares the shit out of me .... we use fentanyl + ketamine in induction dosing for RSI

Are you happy with ambos having amiodarone, adrenaline, adenosine, lidocaine, morphine, fentanyl, NDNMBAs, oxygen, aspirin or any of the other poisons we carry? There is nothing inherently more dangerous about propofol or etomidate compared to any of these other medicaitons.

They can all be harmful if used incorrectly and useful if used correctly.

[Siffaliss]

sorry for asking but what does RSI stand for and what is etomidate?

Ok so the RSI question has been answered. As for the other one, unless I've had too much wine I didn't see the answer was provided in detail ...

Etomidate is classified as an anesthetic or sedative hypnotic (non-benzo/non-barbiturate). It's indicated for general anesthesia or short procedures that don't need skeletal muscle relaxation. It kicks in quick (15 to 30 seconds) but doesn't last long either (3 to 5 minutes), so if you perhaps want to continue sedation after intubating then a longer acting sedative is preferred (such as Versed). It has minimal cardiovascular and respiratory effects, and doesn't promote histamine release when you give it.

They can all be harmful if used incorrectly and useful if used correctly.

... as with any drug out there ...

[kohlerrf]

I don't know if this is on point here however you said you wanted to learn as much about Etomidate as you could for the pre- hospital setting. I use it with every RSI and I am interested to hear it being used for conscious sedation , is seems logical. However let me talk about its role in RSI. Etomidate is a hypnotic sedative well suited for the patient about to undergo intubation. I personally advocated intubating a breathing patient if possible instead of going all the way to sux for many reasons and Etomidate works well to that end. However Etomidate has driven me as well as other medics to administer sux unnecessarily. I have done a some research on this since my event and it has changed my procedure for the better.

I had a patient some time ago who was an apparently otherwise healthy 55y/o athletic male who was discovered by his wife who had just how had left to go to the corner store returning 10 minutes later to find him unconscious and unresponsive. on my arrival the pt was found to have vomited but currently had a clear airway with a GCS of 3 and had no medical history and was not on any prescription medications. Vital signs were WNL and I elected to RSI so as to protect the airway. The issue here is why did I elect to RSI but what happened next.

We hooked the pt up inserted and a nasal airway and placed him of a NRB for pre-oxygenation and started and IV. The pt was pre-medicated with Lidocane because we were unable to rule out a bleed and did not want to increase ICP. We let the Lidocane circulate for 2 or 3 minutes and finished the prep for RSI. Patient Pulsox was no and had been 100% for several minutes and his ETCO2 was 44mm/hg still breathing about 10-12 per min pulse and B/P WNL. I checked the patient and although he had a loose jaw there was still too much muscle tone for me to visualize and the patient still had a gag. I sprayed the back of the throat with a little topical Lidocane and administered Etomidate. After about 1 minute the patient began to stiffen up and develop trismus. I could not open the jaw at all. There was no seizure activity and I feared the worst a possible bleed. I administered Sux paralyzed and successfully intubated the patient and all ended well.

On my follow up and further investigation I sought out the advice of the anesthesiology department at our hospital and others and they all told me the same thing. Etomidate can cause "Myoclonic Seizures" manifesting in the stiffening of the body and trismus. Myoclonis is more commonly seen in leaner individuals and the way to avoid this side effect is to administer a benzo a minute or so prior to Etomidate. Had I known this I could have avoided Sux and from then on I always administer 2-5 mg of versed prior to Etomidate and I have not had that problem since.

Sorry if I took your post to a different place. Hope this helps!

[rock_shoes]

Had I known this I could have avoided Sux and from then on I always administer 2-5 mg of versed prior to Etomidate and I have not had that problem since.

Just curious. If you're using versed as part of your procedure anyway, why not go with fentanyl/versed for your sedation and skip etomidate altogether (assuming the patient has sufficient blood pressure to go that route of course)?

[kohlerrf]

Just curious. If you're using versed as part of your procedure anyway, why not go with fentanyl/versed for your sedation and skip etomidate altogether (assuming the patient has sufficient blood pressure to go that route of course)?

I'm not sure by what you mean "fentanyl/versed" I assume you mean use them together? In any event we do not carry fentanyl only morphine and I'm not sure morphine is potent enough for what you suggest. Also remember that although morphine is a narcotic and the effects of respiratory depression can be reversed with Narcan the hypo-tension that it causes is not. I am going out on a limb here but I assume that fentanyl has the same problem, please correct me if I am wrong.

Lastly we have to expect in any patient that we change from a negative pressure inspiration to a positive pressure ventilation with an ET tube and a BVM will experience a drop in blood pressure, one reason for my above comment about "I would rather intubate a breathing patient". I shy away from agents that have a vasodilatory effect as they can potentiate this common occurance causing real problems. Etomidate nor versed have any vasodilatory effects that I am aware of.

If you meant use either or, I know that versed alone wont do the job in many cases.

[rock_shoes]

I'm not sure by what you mean "fentanyl/versed" I assume you mean use them together? In any event we do not carry fentanyl only morphine and I'm not sure morphine is potent enough for what you suggest. Also remember that although morphine is a narcotic and the effects of respiratory depression can be reversed with Narcan the hypo-tension that it causes is not. I am going out on a limb here but I assume that fentanyl has the same problem, please correct me if I am wrong.

Only carrying morphine explains things completely. Fentanyl is a synthetic opiate analgesic without anywhere near the vaso-dilatory properties of morphine. It’s also shorter acting. Yes, I did mean use them together. Common practice is to only use a Fentanyl/midazolam combination with systolic blood pressures greater than 100mmHg. Otherwise Ketamine or Etomidate usually become first choice for induction agent prior to paralytics.

Lastly we have to expect in any patient that we change from a negative pressure inspiration to a positive pressure ventilation with an ET tube and a BVM will experience a drop in blood pressure, one reason for my above comment about "I would rather intubate a breathing patient". I shy away from agents that have a vasodilatory effect as they can potentiate this common occurance causing real problems. Etomidate nor versed have any vasodilatory effects that I am aware of.

If you meant use either or, I know that versed alone wont do the job in many cases.

Atropine would be very helpful in this circumstance. I don’t know if you carry it or not.

[Paramagic]

I'm not sure by what you mean "fentanyl/versed" I assume you mean use them together? In any event we do not carry fentanyl only morphine and I'm not sure morphine is potent enough for what you suggest. Also remember that although morphine is a narcotic and the effects of respiratory depression can be reversed with Narcan the hypo-tension that it causes is not. I am going out on a limb here but I assume that fentanyl has the same problem, please correct me if I am wrong.

The potency of morphine versus fentanyl is not really relevant: you simply need to give an equivalant dose of morphine to achieve the same effect as the dose of fentanyl you would normally give. However fentanyl has a quicker onset and is indeed less likely to cause hypotension as it does not have the propensity to cause histamine release that morphine has.

An opioid is a vital part of the induction process for drug assisted intubation. Laryngoscopy and intubation causes a rise in ICP due to sympathetic stimulation. This is exactly what we want to avoid when we are intubating someone whom we believe to have issues with their ICP already (TBI, intra-cranial bleed and so on) Fentanyl (as the usual dug of choice) blunts sympathetic response to the procedure and at high enough doses will completely eliminate any sympathetic response. It seems bizarre that you would premedicate with lidocaine which has no proven role in the management of ICP during RSI, yet not give a drug that does have an accepted role.

Lastly we have to expect in any patient that we change from a negative pressure inspiration to a positive pressure ventilation with an ET tube and a BVM will experience a drop in blood pressure, one reason for my above comment about "I would rather intubate a breathing patient". I shy away from agents that have a vasodilatory effect as they can potentiate this common occurance causing real problems. Etomidate nor versed have any vasodilatory effects that I am aware of.

If you meant use either or, I know that versed alone wont do the job in many cases.

Midazolam most certainly does have a significant effect on vasomotor tone and is well known to cause (usually transient) hypotension following bolus doses, probably through it's effect on the synthesis of prostanoids. Loss of cardiac output secondary to this and the loss of the thoracic pump secondary to positive pressure ventilation are always anticipated and very easily managed with appropriate preparation and judicious use of fluid loading to avoid them becoming problematic. If you are siginificantly concerned about the patient's blood pressure and don't want to preload with crystalloids, then the sensible option is to use fentanyl and ketamine along with suxamethonium (or a short acting NDNMBA like rocuronium or atracurium)

To be honest I haven't heard of anyone attempting intubation with sedation alone for a long time. I'm aware of a few services that still have it on hte books for respiratory collapse with the rationale being that the patient would not be able to adequately de-nitrogenated prior to intubation being attempted and thus sedation alone would allow continual respirations. However to use sedation alone, especially with a single agent, on patients with a neurological problem is scary and barbaric.

[kohlerrf]

Only carrying morphine explains things completely. Fentanyl is a synthetic opiate analgesic without anywhere near the vaso-dilatory properties of morphine. It’s also shorter acting. Yes, I did mean use them together. Common practice is to only use a Fentanyl/midazolam combination with systolic blood pressures greater than 100mmHg. Otherwise Ketamine or Etomidate usually become first choice for induction agent prior to paralytics.

Atropine would be very helpful in this circumstance. I don’t know if you carry it or not.

What is the advantage of Fentanyl/Midazolam over Ketamine or Etomidate?

Yes, we carry Atropine but, Why would Atropine be very helpful in this circumstance?

[Paramagic]

What is the advantage of Fentanyl/Midazolam over Ketamine or Etomidate?

Yes, we carry Atropine but, Why would Atropine be very helpful in this circumstance?

See my above post for the reason behind fentanyl being used. It depends on the patient as to whether you use fentanyl/midazolam, fentanyl/ketamine or fentanyl/etomidate.

Atropine is a good drug to have drawn up ready to go whenever suxamethonium is used in RSI. Suxamethonium (succinylcholine) is structurly similar to acetylcholine, so it is not unsual to see bradycardia following it's administration, which obviously affects the hemodynamics. It's not something that happens every time, but it is nice to be prepared for it. It used to be recommended that any pediatric patient recieving sux should get 20mcg/kg, under the assumption that you would notice a more profound effect from sux than in adults, but this has proven to not be necessary.

I have to ask: if you are carrying out drug assisted intubations, why on earth was this sort of thing not covered in your education?

[ERDoc]

I think some are missing the whole point of RSI. RSI is used to control the airway in a pt with an intact gag reflex who has not fasted and has an at risk airway. Using pharmacologically assisted intubation does not eliminate the gag reflex and puts your pt at risk of presenting the stomach contents to the provider and put the pt at risk of aspiration. Even with etomidate alone or versed/fentanyl, you have not eliminated the gag. This is the whole reason for paralysis. The idea is to have the pt sedated and paralyzed in less than a minute, minimizing hypoxia. If you have an unresponsive pt with no gag reflex, there is no indication for RSI or any other pharmacologically assisted method. You just put the tube in. As anecdotal evidence of the risk of not properly controlling an airway, I was recently called to the ICU by the hospitalist taking care of a pt in DKA. The guy was badly acidotic and working hard to blow off the CO2. He was starting to tire and the hospitalist wanted to intubate him. Using propofol only, he tried to place a tube and butchered the airway and never got the tube. I get there and ask for a paralytic but decided to take a look while I was waiting. This guys respiratory effort was so hard that his cords were moving side to side by over a cm as he was breathing. Not a great target to try and hit. Paralytics arrive and the tube goes in with no problem. Without a properly controlled airway, nothing else matters. Do it right the first time.

Others have mentioned pretreating with things such as opiates, atropine, lidocain, etc. There is sketchy evidence, at best, for the use of any of these. Most of the current literature in the EM and anesthesiology journals is leaning away from any pretreatment. Here is an emedicine article that discusses some of the latest studies. Personally, I feel they are a waste of time. It takes time to draw them up in which you could be controlling a tenuous airway and provide no benefit.