Etomidate for intubation?

[scratrat]

Rumor has it, from good sources, that we will be granted the permission to use Etomidate for intubating soon. Our medical director is not fond of RSI, so we won't be getting paralytics. But thats for another topic in and of itself. I do possess the knowledge of RSI from using it at other projects though.

My question is this, say I have a trauma that needs to be intubated, but needs pharmaceutical help. Since etomidate is the only drug added, it's all we can use. After the intubation, we would most likely use valium or versed, both of which we already carry. Moving on, let's say there's is a possibility of head injury, or for arguments sake, some other reason I'm concerned with increased ICP. Would it be appropriate to ask for lidocaine as a premedication, or is that something we would use only for complete RSI? Like with sux and whatnot? Just curious what everyone thinks.

[Ridryder 911]

I personally like Etomidate for sedation, although I much rather have a paralytic on top of it. The good thing is Etomidate is there is not much hemodynamic changes, and short life span.

To your question, I am a proponent of pre-med of Lidocaine. The problem is one has to administer Lidocaine sometime before induction or intubating. Usually 2-3 minutes prior to the RSI or intubation process. Although this can be controversial, personally I don't believe it is not going to harm, and possibly prevent increasing ICP.

Although, some may not recommend since you are not using a defasciculating medication, but remember you may produce an ICP by way of "vagal" through manipulation. I have worked at services that had Atropine & Lidocaine pre-RSI on pediatrics and be prepared for decreased heart rate.

R/r 911

[scratrat]

That's what we used it for too. But I have already heard, as you mentioned, that you may increase ICP just with intubation alone. That's why I was curious if I would get an order for it without using RSI. I also began to wonder why, when we only had versed up north for intubation, we didn't premedicate with lidocaine? Especially since versed is crap, and rarely produces complete sedation, at least in my experience with it. I love etomidate, and yes, I'd love nothing more than a paralytic to go with it, but as they say, baby steps.

[scope2776]

Lidocaine may also be useful for pretreatment of the severe asthma or COPD patient where "numbing" of the trachea and larynx may be beneficial. At least this is what our med director thinks. I may be wrong, but I also recall a side effect of etomidate being increased ICP. We also pretreat pediatric patients with 0.02mg/kg atropine. Our pretreatment dose for lidocaine is 1.5mg/kg. We are able to use 0.2mg/kg etomidate with RSI.

Is your medical director thinking about allowing you to do "crash intubations"? Just snow them with etomidate and tube? If so I hope he's giving you guys tons of education on pre-intubation airway assesment and such. One of the contraindications to RSI here is a Mellienpatti IV, anatomically difficult airway, inability to cric, no combi tube or other bale out, inability to get a mask seal, or just if the medic doesn't think they can get the tube.

After 6 months on the job as a medic, they allow medics here to take the RSI class taught by our medical director, which includes from what i've heard a hard test at the end...

[AZCEP]

An IV dose of Lidocaine will not "numb" anything. In order to get this effect you would have to deliver it topically. It can be done, but takes a bit longer than you would think. 4% lidocaine in an SVN will do a wonderful job of this, but most don't have it available.

The use of Lidocaine for premedication in a head injured patient is still recommended, but the science doesn't really support it too well. Even if it is forgotten, the transient increase of ICP following intubation is best managed by getting the tube the first time.

Adequate relaxation may be a problem using the Etomidate as well, but if you are moving toward RSI, I suppose it is a start.

[paramedicmike]

As has been mentioned, in an emergent airway situation, you're not going to always have the time to give the lido and be able to sit back and let it work (if it works at all which, again, is another topic).

I've done etomodate only intubations with moderate success (failed etomodate only attempts were able to be secured with paralytics...which I know you don't have). Those cases where I couldn't place an ET tube were adequately managed with an LMA.

After the etomodate (if no paralytics are to be given), we are required to spray the oropharynx with hurricaine spray. This seems to help suppress some of the vagal response. Anecdotal, I know. But my experience has been pretty positive. I'll see what I can find on this, too.

It can work and it can work well. Follow up sedation and analgesia do well to help keep the patient comfortable after tube placement. If you can keep them comfortably sedated, the chances of their ICP spiking are reduced (not entirely, but reduced).

Hope this helps.

-be safe

[Doczilla]

Lidocaine may also be useful for pretreatment of the severe asthma or COPD patient where "numbing" of the trachea and larynx may be beneficial. At least this is what our med director thinks.

It numbs them only when applied topically. Many anesthesiologists will squirt lido down the trachea once visualized with a laryngoscope and just before tube placement. I'm not sure how well this works, since lido needs a couple of minutes to really take full effect, and the ETT is placed only seconds after the lido goes down the tube. Another way of approaching this is to nebulize some lido for a few minutes before intubation. I have mixed feelings on this. On the one hand, it numbs the airway, and may blunt some of the reflexes that induce coughing and gagging. On the other hand, since they get numb, they can have more difficulty managing their own airway and secretions.

Lido is injected IV a minute or two before intubation, and it's been found to blunt some of the rise in ICP, which is why we do it. The evidence supporting the practice really isn't great, but somehow it worked it's way into the sequence.

I may be wrong, but I also recall a side effect of etomidate being increased ICP. We also pretreat pediatric patients with 0.02mg/kg atropine. Our pretreatment dose for lidocaine is 1.5mg/kg. We are able to use 0.2mg/kg etomidate with RSI.

That's incorrect. Etomidate is thought to be somewhat cerebroprotective, and therefore okay to use with elevated ICP. It's not as well-demonstrated as it is with a barbiturate, but the effect is there. Perhaps you are thinking of ketamine?

Also, the etomidate dose you have there is a little light. For procedural sedation, 0.15 mg/kg is good, as the patient will stay breathing and maintain airway reflexes. 0.3mg/kg is the dose for induction/intubation.

As far as the evidence goes, etomidate-only intubation hasn't been shown to improve intubation success rates in the prehospital environment. There is a big jump in success rate once they're paralyzed. A lot of docs still shudder at the thought of giving some medics the ability to paralyze patients, and this is a battle that's been fought here at the Regional Physicians Advisory Board for EMS.

The best way to prevent the rise in ICP is to not screw around in the patient's airway for long periods of time. For me, this means paralyzing them. Visualization is better, the attempt is smoother, and it doesn't take so long. That, and if they vomit, they won't do so forcefully, and they won't take a deep breath in and suck that all down into the lungs.

'zilla

[medic001918]

We use Etomidate for intubation at a service I work for and it has worked well when used appropriately. As far as for patients with a suspected head injury, it's in our protocol to give 1-1.5 mg/kg of Lido IVP prior to Etomidate and the intubation attempt.

One of our contraindications for the use of Etomidate is the presence of trismus though, since it's not always going to relax it enough to facilitate the tube (if it ends up relaxing it at all).

We've only had it in the trucks since 02.01.2007 so it's pretty new to us but it's been used a few times with good results.

Good luck,

Shane

NREMT-P

[AZCEP]

Criminy Doczilla, I know I'm just a simple country paramedic, but I already said most of that. :wink:

Glad to know that I wasn't pulling the information out of a dark place though.

[Doczilla]

Criminy Doczilla, I know I'm just a simple country paramedic, but I already said most of that. :wink:

Yeah, yeah, but I said it with bigger words. The bigger the words you use, the fewer questions the patients ask, and the sooner you can get out of a room. My vocabulary expands exponentially in the presence of annoying family members who happen to be veterinary techs/chiropractic assistants/phlebotomists who try to ask a bunch of questions like they know what they're talking about.

Glad to know that I wasn't pulling the information out of a dark place though.

Perhaps it's darker than you think...

'zilla