Etomidate for intubation?

[Spock]

I can only confirm what has been already stated especially doczilla's approach with know it all family members! I revert to six syllable words immediately.

The research supporting lidocaine is old and not very good but it has worked its way into our practice and is used frequently. The rise in ICP is from two factors: muscle fasciculations and the laryngoscopy itself. You can get some fasciculations from etomidate but they are not has severe as with succinylcholine. A smooth and fast laryngoscopy decreases the ICP effect.

Etomidate only intubation is not supported in the literature in terms of success rates although I routinely use only etomidate for intubating in the ICU or on the floor and have good success. The only time I use succinylcholine outside of the operating room is in the trauma bay because I figure I will only get one shot at securing the airway. Pennsylvania just added etomidate statewide and we are uncertain how it will work out. Time will tell.

You must have a good backup airway plan and equipment before you should attempt any form of RSI or SAI. Planning to fail may sound negative but it is safe. Evaluation of the airway to recognize the potential difficult airway is important. The Malampatti scale is an old method and not very accurate. You frequently can't get a very sick patient to cooperate enough to actually perform it properly. Instead, look for decreased mouth opening, protruding upper teeth and receding chin for a more accurate evaluation. If the nose, lips and chin do not form a straight line you have a difficult airway and you may want to think twice before putting somebody down for intubation. How do figure out what is a straight line? Place a pen or pencil on the tip of the nose and see if the lips and chin touch the pen or pencil.

Prehospital I have had good success with versed and fentanyl. Usually 4mg and 100mcg is more than enough to intubate. Versed alone does not work as well unless you give a large dose in which case you will crash the BP. Not a good option.

If you want to pretreat with something other than lidocaine I would suggest fentanyl because it like etomidate does not have a great deal of hemodynamic effect although if you give a lot of either you will see the BP drop. Short half life of both makes this drop in BP transient.

Live long and prosper.

Spock

[scratrat]

First, Doczilla, thanks for that about the use of big words.... I snotted Sprite out my nose!!!

Second, to everyone else, thanks for all of your input..

First, we already versed, which I hate. I used it in New Jersey for 6 years because we didn't have RSI. It NEVER worked. All it did what sedate somewhat and crash their BP. I never ask for it and I'd just rather not give it.

This is still in the works, so I don't know all the details for sure. As far as I know, etomidate and possibly fentanyl are the only two maybe being added. Not sure about fentanyl though. Anyway, in New Jersey before I left, we did use RSI at one project which I took advantage of a few times. A couple of those times, the person was successfully sedated enough to intubate with etomidate alone. They never really educated fully though which was a shame. The couple times I did it, I used everything including paralytics. I was under the impression you had to complete the sequence, rather than stop at etomidate. Then if successful, give valium for prolonged sedation, and vecuronium once tube placement was already confirmed.

Lidocaine her, would be for premedicating only. We don't have topical lido. And we haven't discussed pediatric use of atropine yet. In New Jersey, we were not allowed to RSI anyone under the age of 18. Only the flight crews could do that, and they would premedicate with atropine.

[scope2776]

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.

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

Wow! Thank you for the response!

Maybe our medical director (for our Paramedic program) is mistaken or didn't make the differentiation between topical, neb and IV lidocaine....

It's interesting you use 0.3mg/kg etomidate for RSI. It seems when all the doctors get together to write protocols for EMS IV drugs they decide to give us less for some reason... even paralyzing drugs or sedatives for RSI, even when the point is to make the patient stop breathing. Maybe they think 0.2mg/kg will wear off quicker than 0.3mg/kg. We use Succicholine, for a paralytic, at 2 mg/kg and Veccuronium, once the tube is confirmed, at 0.1 mg/kg adult and 0.2 mg/kg pediatric also. After RSI we have standard protocols for 1 mcg/kg of Fentanayl. It has been my experience that 1mcg/kg won't control most patients pain, so I don't know how that same dose will sedate a paralyzed patient.

I am wrong about increased ICP with etomidate.

[stcommodore]

I don't know if it was said but a featured study by JEMS showed no difference in intubation with Etomidate vs. Versed.

[mediccjh]

I don't know if it was said but a featured study by JEMS showed no difference in intubation with Etomidate vs. Versed.

The study was done in the City of Bethlehem and Bethlehem Townships, PA.

From the medics I've talked to, there were MANY flaws in the study, including patients who should've and shouldn'tve been included that were and weren't.

[tniuqs]

Etomidate Alone versus Rapid Sequence Intubation: a Study in the Prehospital Aeromedical Setting

Vicki L. Huggett, RN, EMT-P; William P. Bozeman, MD; Douglas M. Kleiner, PhD, EMT

TraumaOne Flight Service, Shands Jacksonville, University of Florida Department of Emergency Medicine

Introduction: We sought to evaluate the intubation conditions produced by etomidate (Etom) sedation alone vs. those produced by rapid sequence intubation (RSI) with Etom and succinylcholine (Sux).

Methods: A prospective, crossover trial design used two helicopters staffed by the same flight crew. One aircraft utilized the Etom protocol (20 mg of Etom with a second dose of Etom or rescue Sux available if needed), and the other used the RSI protocol with the same dose of Etom plus Sux (1 mg/kg). After 6 months the protocols were switched. Intubating conditions were graded at each attempt by three different scales: global difficulty using a scale of 1 (very easy) to 5 (very difficult), the Percentage Of Glottic Opening (POGO) score (amount of vocal cords visualized), and formal Laryngoscopy Grading Scale (LGS) resulting in a “good,” “acceptable” or “unacceptable” rating. Orotracheal intubation success was recorded at each dose.

Results: A total of 56 patients were intubated. Conditions were assessed for all 69 laryngoscopy attempts. Evaluations of laryngoscopy attempts using Etom 20 mg only were: Difficulty = 4.9, POGO = 9%, LGS G/A = 13%, success rate = 13%. Etom 40 mg had the following results: Difficulty = 4.4, POGO = 17%, LGS G/A 0%, success rate = 0%. RSI results were: Difficulty = 3.1, POGO = 59%, LGS G/A = 74%, success rate = 90%. Intubating conditions with RSI were significantly improved by all measures (P < 0.05) compared to each Etom alone group.

Conclusion: In the aeromedical setting RSI produced significantly better intubating conditions than Etom at either low or high doses and in turn resulted in higher intubation success rates.

Aeromedical Transport of Severely Head-Injured Patients following Paramedic Rapid Sequence Intubation

Daniel Davis, MD, David Hoyt, MD, Mel Ochs, MD, Jennifer Poste, John Cavitt, CFN

Department of Emergency Medicine, UC San Diego, and Mercy Air Medical Services

Introduction: The San Diego Paramedic RSI Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury (TBI). This analysis explores the impact of aeromedical transport of trial patients on outcome.

Methods: Adult trauma victims with severe TBI (GCS 3-8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; aeromedical crews could be called for prolonged transports. Patients were matched to historical controls using age, gender, mechanism, ISS, and AIS scores for each body system. Aeromedical- and ground-transported patients were compared with regard to demographics, clinical parameters, vital signs, ABG data, and outcome. Regression analysis was used to determine the independent effect of aeromedical transport on outcome.

Results: A total of 352 patients were included (87 aeromedical and 265 ground transports). There were no significant differences between the groups with regard to demographic, clinical, vital sign, and ABG data. Aeromedical patients had decreased mortality (28% vs. 31%, OR 0.9) and ground patients had increased mortality vs. matched controls (33% vs. 22%, OR 1.8). Regression analysis revealed a decrease in mortality (P = 0.011) and an increase in “good outcomes” (P = 0.046) associated with aeromedical transport.

Conclusion: Aeromedical transport of paramedic RSI patients is associated with improved outcomes.

Yea I know its not tottally ON TOPIC, but thought I would post fer fun.

[Novisen]

I use Propofol and Celo on RSI. I also have Ketamin and Midazolam if I want to.

[Asysin2leads]

Etomidate works well for facilitated intubation, and by some weird quirk of law, its not a controlled substance. The two biggest prehospital concerns, in my opinion, are its viscosity and its relatively short duration of action. If you look at the bottle, the solvent is propylene glycol, which is also used in antifreeze. As per my medical director, this makes it even more viscous then D50, so, in other words, make damn sure your IV is good before administration.

The second is its relatively short duration of action. I can't rattle the duration of action off of the top of my head, but from anecdotal experience, it is not very long. In my opinion, a person should not be intubated without a following dose of a benzodiazipine. When we first got our etomidate, as the story goes, a telemetry doctor granted the etomidate but not diazepam, and, well, the story ends with a paramedic nearly losing his finger to the teeth of the patient. Otherwise, its good stuff.

[Doczilla]

Propylene glycol is a very common diluent for many injection medications. It is used in antifreeze, but the more "environmentally friendly, non-toxic" kind (Sierra is one brand). In really large quantities it can be dangerous, but not in the quantities typically encountered with injection meds. Propylene glycol is much safer than ethylene glycol (the common ingredient in most commercial antifreeze), which can cause renal failure, acidosis, and death in pretty small quantities.

Etomidate is a prescription drug but not a controlled substance, mostly because people haven't seen fit or found a way to abuse it.

I've drawn and pushed a whole lot of etomidate, and I would not agree with your supervisor's statement that it is more viscous than D50.

Onset of action of etomidate is 30-60 seconds, and duration is approximately 10-15 min. This is important to remember if you push etomidate and a long-acting paralytic such as vecuronium or rocuronium; the patient may wake up and return to full consciousness before the paralytic wears off. I agree completely with giving a benzo (in large doses) to a patient after giving etomidate and the airway is secure.

'zilla

[EMS49393]

Wow! Thank you for the response!

Maybe our medical director (for our Paramedic program) is mistaken or didn't make the differentiation between topical, neb and IV lidocaine....

It's interesting you use 0.3mg/kg etomidate for RSI. It seems when all the doctors get together to write protocols for EMS IV drugs they decide to give us less for some reason... even paralyzing drugs or sedatives for RSI, even when the point is to make the patient stop breathing. Maybe they think 0.2mg/kg will wear off quicker than 0.3mg/kg. We use Succicholine, for a paralytic, at 2 mg/kg and Veccuronium, once the tube is confirmed, at 0.1 mg/kg adult and 0.2 mg/kg pediatric also. After RSI we have standard protocols for 1 mcg/kg of Fentanayl. It has been my experience that 1mcg/kg won't control most patients pain, so I don't know how that same dose will sedate a paralyzed patient.

I am wrong about increased ICP with etomidate.

The last service I was employed for utilized RSI. Our lidocaine dose was 1.5 mg/kg in patients with suspected head injuries, including CVA. Etomidate was 0.3 mg/kg, and Succs was 1.5 mg/kg adult, and 2 mg/kg pediatric. We also used atropine at 0.02 mg/kg in patients under 10 years old. We had standing orders for Vecuronium if Succs was contraindicated. We had standing orders for one dose of Versed for tube tolerance and ability to contact medical control should we need to use Vec to continue to paralyze or required more doses of Versed for sedation. We have standing orders for fentanyl up to 200 mcg.

I have used fentanyl numerous times before arriving to a service that doesn't stock it. I've had great success with it, especially in little, elderly ladies with broken hips, or to control pain in elderly cancer patients during transport. We had standing orders for pain control, so it was my call to attempt to deliver pain control. I've personally had as little as 20 mcg control pain in a patient before.

As far as numbing the trachea, we had these wonderful devices called LTA jets, Laryngotracheal anesthesia jets. I tried to use one once on a COPD patient I wanted to intubate but wasn't sure I wanted to paralyze. I never made that mistake again. RSI is, IMHO the most humane way to control an airway.