Etomidate for intubation?

[chbare]

I understand your position; however, I have taken care of a couple of patients recently that suddenly decompensated as a result of a massive MI. Unfortunately, they not only decompensated hemodynamically, their level of consciousness became severely depressed. I was able to place an NPA and perform BVM ventilations without resistance. CPAP or BIPAP would not have been an option in these patients and RSI was required to establish an airway. (Inside a tiny A-Star 35 minutes from the nearest hospital)

I do not have a problem with ketamine per say, I am simply not sure that I would want to use it as my only induction agent. However, I am in the same situation as you. We utilize Etomidate as our primary induction agent, so my comfort level is quite high when it comes to using Etomidate. My experiences with Ketamine are limited to my ER experiences where we did conscious sedations on patients. (Mainly orthopedic procedures) I find that patients should also have a benzodiazepine on board to blunt emergence reactions.

Take care,

chbare.

[Novisen]

Hello chbare!

As I wrote earlier RSI on vital signs is needed now and then. I´m not waiting until patient become unconscious. Stunning myocard with hypotoni (chock) is more often seen in inferior and diafragmal MI. Dobutrex, Dopamin or Adrenalin (and Simdax) + volume + intubation can give you some time before the patient dies. Early diagnosis and treatment with PCI or trombolytic agents. We carry Rapilysin in our cars but the patient needs his/her bloodpressure for the treatment to be succesfull. One problem with RSI is the high grade of failure in prehospital settings. To performe a succesive RSI with minimal deacrease or increase of bloodpreasure is hard. You never know how your patient going to respond on the anhestetic agents. Remember that all clinical resersch is done on healthy male volonters.

[firemedic54]

We do RSI here in our county (Livingston,MICH.) Our med.control removed the lido. says no real evidence about ICP. However, we can only do trauma RSI, not medical i.e. chf pt's.

[firemedic54]

And we do both etomidate and succ. with versed as a maint. Seems to work well.

[Darthmedic]

Ok am new to this fourm. So, has anyone taken the difficult airway class? There are 3, one for ED doc, the other CRNA, and one for ems providers. I took the one down in FLA two years ago. It was a great class. Goes over most of the current thought and medicine. Shows some new tricks and toys. Two day immersion class that I would reccomend to all paracticing people.

Be safe.

[paramedicmike]

I've taken the class and found it very worthwhile. Apparently, so did my boss and several coworkers who are also instructors for the class.

-be safe

[Spock]

We just started a new airway class called Advanced Prehospital Airway Management (APAM) here in Western PA. The region got a big grant to pay for the course and all paramedics are expected to complete the class over the next few years. The course is free and the instructors are well paid. It is an 8 hour class and is scenario based. Everyone that has completed it so far loves the class and they take away many useful skills as well as new insight into the decision making process involved with airway management.

Live long and prosper.

Spock

[tanman70@hotmail.com]

Etomidate In many cases will work fine alone like has been mentioned by many other replies here but paralytics are nice to have for a back up in a RSI situation,Lido jelly applied to your tube helps with numbing your vagal response,in the system that I work for we are very agressive in the manner of RSI

We carry Vec,Succ ,Versed,Etomidate,Ativan so we covered in about all situations we encounter

One thing that you do want to watch with versed if you have or will be getting it is one of the side effects is hypotension and it will cause there pressures to drop I have seen this first hand

And secondly something that you might want to discuss with your medical director is if your first dose of Etomidate does not produce the effect that your looking for is may you give a second our medical director in our system allows this

and 2 dose will usually snowball anyone

Good Luck

[chbare]

I am not sure I agree that Etomidate alone should be the primary modality. True, Etomidate may produce favorable intubating conditions. RSI without a paralytic in my mind is suboptimal. You still have to worry about laryngeospasm and intact muscle movement/tone. This can set you up for serious problems. Remember the goal of RSI is to attain a high first attempt success rate. Without that addition of a paralytic, you are producing suboptimal conditions for first attempt success. (IMHO)

In addition, giving subsequent doses of Etomidate is asking for adrenal suppression. While this is treatable in the hospital, it can be lethal and lead to many problems.

I agree that you need to cautious with Midazolam when taking blood pressure into consideration.

Take care,

chbare.

[paramedicmike]

I'm inclined to agree with chbare. While there are cases where an etomidate only intubation attempt can be considered, it doesn't create the best situation in order to place an ET tube.

And I have to say, masseter muscle spasm is much more common with etomidate administration than one might otherwise think. I've seen this more often than I'd like to think about. It was nice to have the succs as a follow up in order to be able to successfully place that ET tube.

We have as part of our advanced airway considerations an etomidate only discussion. There is a place for it. But there's enough involved that I don't like to try it unless there's really no other option.

-be safe