Etomidate

[PHMEDIC93]

Any services carrying Etomidate for medicated airways? We are getting it on our rigs within the next few weeks. Wondering if anyone has any tales. Good or Bad

Thanks

[dousaems]

No tales yet, but it is an option in our RSI protocol. The doc behind this program loves it, even over succinylcholine. Our county has done a few RSIs, but I haven't received the feedback as to what they used. But I can tell you that there are not a whole lot of services using yet. Seems to be a bit controversial. If you folks get to use it soon, let me know if you have the good results that so many people say it results in.

[JimMccarthy]

Used to use it all the time in the ER for intubation. Not sure if my dept uses it or not. (Just a newbie!) But, I liked it as well or better than Succnylcholine.

Stay Safe, all

Jim Mc Carthy, RNC (Emergency Med)

[GARR]

Our service are in the process of revamping are protocols. We looked at Etomidate and the way I understand Etomidate is a potent sedative and not a paralytic. So we did some investigation into new paralytics and found "Rapalon" this is a new drug witout all the side effects and contraindications such as Succ's or Verconium. It has a short down time such as Verconium. It can also be used on burn patients and peds safely. Sorry I don't know more about Etomidate.

[buzzmedic]

In the Panhandle of Texas, we have Etomidate in our protocals. We used to carry a strong paralytic, but was discontinued in favor of Etomidate. Our protocals call for 4mg Etomidate with 2mg of Versed. Only drawback being Etomidate is short acting which means that you have to continue administering Versed about every 5 minutes or so to keep the patient down.

buzzmedic

[CAR 11/FFPM]

Etomidate and sux are different class of drug. the etomidate is a sedative, alot is needed and it is expensive, short half life is good. Diprovan is a good sedative and cheaper. Sux is a paralitic not a sedative.

[PHMEDIC93]

Well, we got the Etomidate, I wrote the protocol for 0.3 mg/kg max of 0.6 mg/kg. The other service I am working for uses 0.3 mg/kg then moves straight to versed chased with sux (that always works). We aren't carrying sux yet but I wrote in there Versed can be used to keep them down or to help with sedation.
I know some places don't bother with the versed if they are using Etomidate.
What dosage of Etomidate are servies using. I read in the drug guide you can go 0.2-0.6mg/kg.

[big b]

I am currently researching the use of RSI in the prehospital setting, and am in dire need of what other departments are using as well as their protocols for use and tracking of sedatives and paralytics used. Any help would be greatly appreciated.

[mike m]

in the New York City ems ststem all the narcotics we carry are Valium,Morphine and Vercette.we have no protocol for RSI as of now.as far as conscious intubations i have found no problems with using valium or vercette when intubating,but it would be nice to have Suchs as another option.I can remember 20 years ago, sedation for a conscious intubation was for your partner to sit on the patients chest while you tried to pass the tube.as far as tracking the use of narcotics,after we use the narcotics we call medical control and give all the pertinent info and document on our call sheet.

[Bleve613]

RSI has proven to be controversial in the pre-hospital setting. It is important to realize that there is a difference between rapid sequence intubation (RSI) and conscious sedation. RSI requires the use of a paralytic and conscious sedation only utilizes sedation with a benzodiazepine in most cases. In my experiences it is extremely difficult to intubate utilizing only the sedation. In order to truly "put someone down" you need to give a paralytic. Succinocholine is a common paralytic used pre-hospital. It has a short half life and you can determine the onset after defasiculation occurs. The fasiculation can potentially be a problem if dealing with a spinal injury. I personally believe that EMS systems are making the wrong choice when they don't include a paralytic in the protocols. Paramedics can cause more damage when attempting to intubate someone who isn't truly sedated. Most patients who are given etomidate will take a higher dosage then providers are able to administer to truly knock out the gag reflex. Hope this information is helpful to you. Any questions feel free to contact me at Bleve613@firehousemail.com.

[This message has been edited by Bleve613 (edited 05-19-2001).]

[spo0k]

The department I currently work for carries etomidate and have had great luck with it. ER docs in this area seem to love it as well because it doesn't completely knock out the airway, rather it simply anesthetizes the patient. Combined with 2-4 of versed, it works great.

I have also worked for a service that carries both succs and vecuronium. I read a lot of liturature on both and found that succs actually raises intercranial pressure after administration while vec does not. The downside to vec is that 0.1mg/kg will last for a whopping 40-45 minutes, which is obviously a long time if you cant get an airway. I read the drug information sheet on etomidate and didn't find any mention of its effect on ICP so i can't speak for that, but I know it only lasts for about 10 minutes, so a longer transport time will require resedation.

Just my recent observations, hope thats what you were looking for...



------------------
FF. Mike Burnes
Whitehall Fire Division

[bone68]

We have etomidate in our RSI protocol and have had good experince with it. One thing noted in the lit is that if pushed too fast it might cause vomitting.

[phyrngn]

We use Etomidate, and for the most part, like it very much. Last year, our RSI protocol called for Mivacron and Mivacron only. That drug was not looked upon favorably by field providers, as if it wasn't given correctly, could cause a pt to code; not to mention the fact that the pt knew everything that was going on. We are given the option (for induction) to give either 2 mg of Versed or 0.3 mg of Etomidate. As I am a new Medic, I've only given it a couple of times, but it has worked well. We are to give Succs (1.5 mg/kg) after Etomidate (if needed), however the Medics that I have worked with very rarely move on to Succs as the Etomidate works just fine. After the pt is intubated, we use Versed to keep them sedated.

[Ohiofiremed57]

Buzz. Are you sure on the 4mg of etomidate? That seems a little low. My protocol states .3mg/kg of etomidate and 5-10mg of versed. Which in the average adult translates to 30mg of etomidate and 10 of versed. Works well I might add.

[mistymjo]

We received Etomidate a couple of yrs ago for facilitated intubation for combative pts. or pts. w/gag reflex needing an airway. I was struck by one major difference between our way of using it and the way mentioned several times by preceding posted replies. We have a choice of Etomidate 0.3mg/kg up to 20mg x1 or Versed 5 mg as initial drug txs. Yet some of you combine the 2. Maybe that's why Etomidate on combative/teeth-clenched head injury pts. is pretty much ineffective. I wonder...

[Air1fltmedic]

I have seen good results with the Central New York Protocol for facilitated intubation. Etomidate 0.3 mg/kg IV over 30 to 60 seconds (max total dose of 20mg) or Versed 5.0 mg IV (additional versed or valium if intubation is successful) Also they have Flumazenil given @ 0.2 mg for valium/versed reversal. It my personal opinion that airway management is important, (I think I read that in a book)and all ALS providers (ground+aeromedical) should have this as an option in thier protocols.

RSI works really good too. It requires in my opinion the additional training in Surgical Airways. I think ALL Aeromedical services should have this training.

Now both of these really should be Standing Orders!!! We don't ask permission to Defibrillate, we shouldn't ask to secure a patent airway.

Training,CME's, and QA/QI are the key.

Don't move to Maryland and have a medical emergency or trauma that requires aggressive airway managment. We are behind the times, ONLY MY OPINION!!

Stay safe,

[ 09-02-2001: Message edited by: Air1fltmedic ]

[ 09-02-2001: Message edited by: Air1fltmedic ]

[OhioMedic27]

Couldn't agree more with air1fltmedic when he/she says that airway management should be a standing order. Regardless of the approach you take, be it sedation or paralytics, ALS providers should have the tools to get their job done. Protocols are not only standing orders but are guidelines that should not be written with the purpose of handcuffing your providers.

Training is the key to any procedure and any RSI protocol that includes paralytics should include surgical crics as well.

[PHMEDIC93]

First off, thanks for all of the input on the Etomidate. We haven't used it still. It has been a slow summer for the most part. Slow is alright though!
An interesting story that came from the grapevine about medicated airways/paralytics. There is a medic that paralyzed a traumatic head injury with a helicopter circling overhead. They then intubated the patient and turned the chopper around. The medic is has got in some trouble over it because there may or may not be some litigation pending. The paper reported the family might be seeking punitive damages because this patient isn't the same. If I were not medically trained sitting on the jury and if the proscuting attourney was worth his ass. They would have figured out the place where the guy was injured has a huge landing zone, plus this helicopter can load an unload hot (with blades cranking).
They only have to prove beyond a preonderance sp? of evidence that this action caused harm. It will be an interesting case. It is unfortunate to see this paramedic get nailed because they are one of the more skilled medics in the area. However one choice they made got them in more trouble than they wanted. Moral of the story be careful. I'm sure you all know this.
To the flight medic that posted before this.....you lucky bastard....I want your job!!! You guys are the ****!!!! :)

[Bkdraft79]

I am replying to this posting as a fairly new medic and a former ER tech with 3 years experience. Etomidate is not a paralytic and must be used with one (such as Sux and/or Vec). I have administered and observed Etomidate therepy quite a few times and have had excellent results. Etomidate is a better induction agent than Versed as it works much faster and is more accurate (I.E. titration of versed). However, keep in mind that Etomidate (in a dose of .3mg/kg) wears off quickly (within a few minutes)and must be followed with a Versed (if that is what your protocol calls for). I am by no means an expert in the field of Anestetic therapy but have had several conversations with CRNA's about this topic and they tend to agree.

[Bkdraft79]

I am replying to this posting as a fairly new medic and a former ER tech with 3 years experience. Etomidate is not a paralytic and must be used with one (such as Sux and/or Vec). I have administered and observed Etomidate therepy quite a few times and have had excellent results. Etomidate is a better induction agent than Versed as it works much faster and is more accurate (I.E. titration of versed). However, keep in mind that Etomidate (in a dose of .3mg/kg) wears off quickly (within a few minutes)and must be followed with a Versed (if that is what your protocol calls for). I am by no means an expert in the field of Anestetic therapy but have had several conversations with CRNA's about this topic and they tend to agree.

[taidan]

Yes etomidate is great! not only does it have a short halflife/ onset it has minimal effects on Hemodynamics. Etomidate actually decreases ICP while at the same time decreasing cerebral oxygen consumption. Double plus for a head injury

[Weruj1]

We also use Etomidate and Versed ....have not had any trouble with it.

[RoryEl]

Etomidate is a good med for sedation induction. Fast acting, short duration with good cardiovascular profile. Normal dosage is 0.3mg/kg IVP over 30 to 60 sec. If sedation is suboptimal follow with versed.
I'm not in favor of prehospital use of Diprovan. I've used it and believe Etomidate, Versed and Ativan is adequate. Succinylcholine is a good first line paralytic for field use. The problem I've seen with RSI or MAI is the gee whiz factor. Look, I've got a new toy that I want to try out on ... YOU. The procedure needs a strong QA program to ensure adequately skilled PM's, strong on and off-line medical control, and thorough review with trend analysis. Its a high risk, low frequency procedure just like crics. There's a companion thread about RSI that is interesting and reiterates the degradation of the value of ACLS when BLS needs are not met.
The coma cocktail I use most often without ICP or pediatric issues is:
Etomidate -> Sux -> intubation -> versed. This will give you a few minutes to treat & monitor your pt and then prepare to keep them induced. For continued induction I usually use a longer acting sedative like Ativan and longer acting paralytic like Norcuron. Once in the hospital, where hemodynamic monitoring is available, Diprovan or ativan titrated utilizing TOF monitoring is preferred. My protocols allow for some discretion in selection of agents, however it is limited and in the hospital you generally get what the doc is use to using.

Occasionally sedation is adequate without paralytics but this isn't conscious sedation. Conscious sedation and RSI are different procedure with different management, objectives, and outcomes.

I hope this helped answer your question

PS if you can't get them tubed while keeping em oxygenated, fall back on your BLS airway - bag em - and get them to someone who is more skilled (ED doc)

[mittlesmertz]

RoryEl- we also use Etomidate with Succ for RSI, with good results.
I'm unfamiliar with Diprovan, what class is it? (yes i could look it up, but that's no fun).
For extended transports we utilize Veccuronium, with versed as sedation.
The EDs here usually start them on Propofol for continued sedation-although maintaining a balance between adeqaute sedation and hemodynamic stability can be tricky.

[medic563]

diprivan is propofol

[mittlesmertz]

I love the forums, it makes me feel smart.:)
Thanks!

[medic719]

Some very interesting comments here. Good thread! Let me give a few of my thoughts:

It does appear that there is a misconception about the types of medications being discussed here. Car11/ffpm made a comment on this. Etomidate and Succinocholone were mentioned several times as being the same class of drug and used for a similar ariway management protocol. This is not correct. Let me say: Etomidate is a sedative and Succinocholine is a chemical paralytic. RSI (Rapid Sequence Intubation) is the use of a sedative and a paralytic to obtain a patent airway through endotracheal intubation. Facilitated Intubation is the use of sedatives and benzodiazapines to achieve intubation. Two different procedures with different pros and cons. Both work. My personal preference would be RSI due to the fact that you can achieve complete paralization, easing the intubation. Just a reminder: Using chemical sedation/paralization is a tool to be used for gaining a patent airway in the event that all other forms have been exhausted. Most commonly seen in trauma related head injuries with combative patients who need an airway. If you are not comfortable with your intubating skills DO NOT ATTEMPT THIS!!!!

I disagree with Bleve613 on the comment that RSI should be contraindicated in the pre-hospital setting. I have utilized this tool numerous times and it has made all the difference. Like I have read several times in this thread... QA & Con-Ed are key. Granted, this skill is not used every day... but it does have it's place.

Thanks.

[mittlesmertz]

Um,, not to sound rude or anything, but please tell me you didn't just post on the ALS boards describing how RSI works.
And, from my experience, the vast majority of RSI's are done for medical pts (CHF/COPD/etc) as opposed to RSI for TBI pts.

Read some of the older posts to get a feel for the level of experience these posters are at. They are waaay beyond the "average" level of knowledge in most paramedics. Just a thought, these posters are very sharp, and rarely need the "basics" explained.
Welcome aboard, by the way!

[medic563]

Not to mention some of the posts are years old.

[medic719]

Well... not to be rude back... but... If there are 'experienced' clinicians here, then they should know that Etomidate and Succinocholine are not the same class of medication. And there were several comments made referring to RSI and Facilitated Intubation being the same, which they are not. That was my only suggestion. I wasn't demeaning anyone's 'experience'. Not tryin to toot my own horn, but with 15 years under my belt (10 or those in NYC) I'd say that gives me a little experience as well.

BTW, you commented that the vast majority of RSI is done only on medical patients. Maybe where you come from. In the Northeast RSI is used for ANY patient needing a definitive airway. That includes trauma patients.

So... to all the 'experienced folks' out there... sorry if I 'offended' any of you. Just making my observations, like most of you. No harm intended.

[medic563]

When did NYC get RSI? By the was its succinylcholine or anectine. And be just over the border is one of those Northeast states, I agree that RSI is used for any patients with a definitive airway, we do medical and trauma about 50/50. As I commented on after the initial post, check the dates. This was an old post the got revived with some of them going back several years in which alot of services were just getting into RSI or facilitated intubation. Welcome to the forum though.

[medic719]

NYC has never had RSI. At least when I was there. Never said NYC had RSI. Just stating where some of my experience came from. I had some flight experience in Syracuse N.Y. where we used RSI extensively. BTW, never said I had perfect spelling (s u c c i n y l c h o l i n e ) Sorry for the grammatical error.

Again, I'm not bashing anyone's 'experience'. Yes, I know that this thread started a few years ago. My only observation and comment was that the two medications, Succinylcholine and Etomidate were NOT the same class of drug. And RSI / Facilitated Intubation, altough used for the same end point, were NOT the same procedure. That's it. Just my comments. No harm ment. Really.

Thanks for the input.

[mittlesmertz]

Just curious as to what type of response area is running 50/50 medical vs trauma calls?
From the literature I have read, particularly when RSI is introduced to an EMS system, the ratio of medical vs traumatic RSI is usually about 3-4:1. Curious to know what type of system you're in that sees a different percentage.

[medic563]

I'll be completely honest, these are just estimations from my personal expierence and speaking with medics that have been in the system since the very begining. WE do a lot of traumatic RSI's because we cover a lot of area with alot of roadway, and alot of bad drivers and no local trauma center so were either in for a 30-45 minute ride or helicopter if its flying. The CPAP and shorter transport times for our medical patients usually mean some that we may consider doing, are not because we're around the corner from a local hospital. You have sparked my interest though, and I am going to see if I can find out the offical ratio. And we are a very interesting system when it comes to operations that may have something to do with it.

[ufmedic]

We give etomidate with 5mg of valium. etomidate can cause a very painful myoclonis once the patient awakens, but valiun is a muscle relaxant and counteracts the myoclonus...plus it sedates like all other benzodiazipines.

RN,BSN,CCRN,NREMT-P

[vfddoc]

Anectine is the trade name for succinylcholine (it's also sold as Quelicin) Doc

[medic563]

Yeah. I know. I was just being difficult. :D

[mcad64]

Etomidate (0.2-0.4 mg/kg IV) is an ultrashort-acting, nonbarbiturate hypnotic agent that has been used as an induction agent for anesthesia for years.16

Etomidate has minimal hemodynamic effects and may be the drug of choice in a hypotensive or trauma patient.17 It causes less cardiovascular depression than either the barbiturates or propofol. Etomidate has been shown to decrease intracranial pressure, cerebral blood flow and cerebral oxygen metabolism. For these reasons, etomidate is probably the sedative drug of choice for prehospital RSI. Etomidate may decrease cortisol synthesis with one dose. In appropriate patients, steroid replacement may be used to offset this action

[mittlesmertz]

Mcad64, just curious, did ya pull that as a quote from somewhere?
(what are the numbers after the sentences?)
We should all give credit to any refernces we pull, if that's the case; it's nice to the authors, and avoids legal issues.

[mcad64]

mittlesmertz Mcad64, just curious, did ya pull that as a quote from somewhere?


Got it from a hand out from a class I took with Bob Page.. It had no author on it......... I guess my hands type stuff maybe I need to proof read...........Phu-lezz someone get my hands offa keyboard I'ma typin as fast as I can:D

[sparkymedic83]

Back to the original question....

Our RSI protocol is as follows:

Adult:

Lidocaine 1.5 mg/kg if increased ICP
Etomidate 0.2 mg/kg or Versed 1-5 mg
Vecuronium 0.01 mg/kg Defasciculating Dose
Succinylcholine 1-1.5 mg/kg
Intubate
Vecuronium 0.1 mg/kg

We can then give versed and vec as needed to continue sedation/paralysis.

Pedi:

Atropine 0.02 mg/kg
Lidocaine 1.0 mg/kg
Versed 0.1 mg/kg
Vecuronium 0.1 mg/kg

Continued sedation / paralysis as needed.

I agree with mittlesmertz as well. Our RSIs are probably 4 to 1 medical to trauma, respectively.

-- J.Jones

[medic563]

Still waiting to hear back from the guy that compiles all that info, but unoffial polling so far guestimates 60/40 with it being 60%^ trauma in sumeer and 60% medical in winter. I'll repost when I get asome actual hard numbers.

[mittlesmertz]

In regards to lidocaine pre intubationf for suspected ICP, I thought this had fallen by the way side,as few studies had shown its efficacy, particularly in the field setting.
We discussed it on here previously, but it has to do with the timing of the initial dose.
It was taken off our protocols about 1 1/ years ago.

[medic563]

Ok Mittle,
Got the word back from the airway CQI guy. 60% medical, 40% trauma pre-CPAP. We've only had the CPAP about 6 months and so far it looks as though that number is going to become closer. So far had 6 that would have probably been RSI'd that have been brought around or at least held at bay until pharmacological treatments could begin working effectively. I'm curious to see what the number will be in a year.