Etomidate for intubation?

[als_medic_uk]

Etomidate is a good sedative for RSI; it is advisable but not a necessity to give a preventative dose of hydrocortisone, as Etomidate as a long term sedative (ICU) can increase mortality rates due to the suppression of steroid production. However, there is no evidence that a single dose can cause this suppression. It is not used in the critical care environment, only in the emergency care scenario. So with its short half life and relatively low LD50 comparison it is an effective RSI sedative.

Regards.

[paramedicmike]

Etomidate only for a facilitated intubation can be a good thing. But I really hesitate to use it alone without the possibility of paralyitcs to follow. Masseter muscle spasms can be a big problem with Etomidate. And if you don't have paralytics to follow up then you'd better hope you can bag through that clenched jaw.

I realize this is only anecdotal, but the last four RSI attempts I've made have all had Masseter muscle spasms on Etomidate admin. Fortunately, we had the paralytics with which to follow up. But it seems to occur a little more frequently than my reading/research suggested.

Just something to keep in mind. Masseter muscle spasms can and do happen with Etomidate.

-be safe

[Novisen]

There´s a lot talk about RSI among paramedics. Should´t we talk about how often it´s necessary to perform RSI in the field. If it´s necessary my opinion is that Ketamin and Celo is the only drug we need. And that´s for trauma and traumatic head injuries. CHF, OD, mm should never be intubated ather then on vital signs and when not responding on treatment. Someone doubt my competence?

[Doczilla]

If it´s necessary my opinion is that Ketamin and Celo is the only drug we need. And that´s for trauma and traumatic head injuries. CHF, OD, mm should never be intubated ather then on vital signs and when not responding on treatment. Someone doubt my competence?

Novisen-

This last statement of yours may be construed as a challenge to start an argument, and not in a nice way. I suspect that it is simply a matter of things not translating quite right from your language to ours, and that you did not appear to be rude.

If you did, then I am more than happy to accommodate you.

'zilla

[Novisen]

Sorry Doczilla and everyone else if I´m understand that way. It wasn´t my intention. To performe RSI in the field is difficult and should´t be attemt if there´s no direct threat to the patients life. And when so is Ketamin and Celo is the only drugs you ever need (challenge from my side). Ketamin do not reduce bloodpreasure as much as Entomidate in patients with a high level of catekolamins like the trauma patients and head injuries. Systolic bloodpreasure increase beetween 0-40% when Ketamin is used in non bleeding, young, healthy male patient in the OR. 1mg/kg in trauma patients is enough before intubation.

[fiznat]

Protocols in my area have no allowance at all for RSI, or even sedated/assisted intubation. We are allowed to give 5mg Versed POST intubation, but that is it. All in all it is pretty weak, I think, and we are in need of a little more progressive protocols in this area. I admit I have only been a completely cut loose medic for about a month and a half now, but I personally have already had one or two patients for whom I would strongly consider RSI. It is used routinely in the hospital with excellent success, and with our availability of backup airways (Combitube and soon the LMA) I truly do not understand what the holdup is with this protocol. We are given standing orders for surgical airways, but not RSI? It doesn't make sense to me.

A doc I recently explained this to, and who was unaware of our current protocols, was amazed to hear that we didnt have RSI. His quote: "So basically, either the patient is dead, or you're not going to be able to get the tube?" I'd like to think that our success rate is a little higher than that, but all in all it is kinda true. What is the holdup here.

[Code 8 Paramedic]

I think for the most part it is true. Either the patient is so obtunded that they can take the laryngoscope, or we have to wait for them to get that way. And if they are that obtunded they are almost dead. I agree that we see plenty of patients who need to be RSI'd, I think with "my other service" our being able to use etomidate to intubate will slowly move out to the rest of the region. Also did you know that at "that college hospital" every service with R5 control gets RSI?

[paramedicmike]

Look at it this way Fiznat. I'm sure you know people in your service who shouldn't be working the street much less RSI-ing people. Well, the docs see that, too. Which is why you have no RSI protocol.

I'm sure you've thought of that. Sometimes it helps to know that just about every system out there has something along those lines.

-be safe

[chbare]

Novisen, I would like to discuss the use of Ketamine for RSI. I agree that Ketamine does have allot to offer;however, my concerns about using Ketamine as the only induction agent for all of my RSI's are related to the physiological responses you discussed in your previous post. If I have to RSI a CHF patient or a patient having a missive anterior lateral wall MI with fulminating pulmonary edema, I am not so sure I want to give a med that will increase heart rate, myocardial oxygen demand, and secretions. I understand that we should not intubate every patient; however, these kinds of patients may not allow us any other option, and I am not sure I want to be pushing Ketamine as my induction agent. The reason I like Etomidate is because in many cases the patients hemodynamic response is minimal.

Take care,

chbare.

Take care,

chbare.

[Novisen]

Hello chbare!

Anterior lateral MI + fulminating pulmonary edema = left forward fail. You are absolutely right. Induction with Ketamine shouldn´t be attemt. Entomidate or Versed is an better option. But do you have to RSI these patients?

We have used CPAP prehospital for 15 years now and I have never get to the position that I have to RSI an patient with AHF or an CHF. CPAP to reduce preload and Nitro to reduse preload and afterload in the first place. Morfin and Lasix can be added related to patients permission later on. CPAP, not RSI is the answer :wink: .

Interesting reading about Ketamin to THI patients.

http://meetings.acep.org/NR/rdonlyres/AE1F...uryCarcillo.pdf

Suggested sedatives for selected clinical situations

Clinical Scenario Options

Normotensive/euvolemic Thiopental, Versed, Propofol

Mild BP and head injury Thiopental, Versed, Etomidate

Mild BP, no head injury Ketamine, Versed, Etomidate

Severe BP Ketamine, ½ dose Versed, Etomidate

Status Asthmaticus Ketamine, Versed, Propofol

Status Epilepticus Thiopental, Versed, Propofol

Isolated head injury Thiopental, Propofol, Etomidate

Combative patient Thiopental, Versed, Propofol

Entomidate is not for sale in Sweden so I shouldn´t comment a drug I don´t have personal knowledge about. We carry Versed, Propofol and Ketamine there I work.