# Etomidate ---> Jaw clenching? Coincidence?



## NYMedic828 (Aug 18, 2012)

So we had a respiratory failure with presumed aspiration this morning 2nd to vomiting. (stage 4 lung CA, no DNR/DNI.)

Unconscious, hypoglycemic, hypoxia sat in the low 80s. Normotensive, normal sinus.

Anyway, we BVM for a little no improvement and has a gas reflex. Set up for intubation, administer 20mg etomidate and he goes out fully. Partner goes to tube, jaw fully locked. Had to bag the rest of the trip.

Is this just a coincidental occurrence with when his body decided it felt like clenching up or was it etomidate induced?


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## MSDeltaFlt (Aug 18, 2012)

He wasn't sedated enough.  He needed more.


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## usalsfyre (Aug 18, 2012)

Trismus is a side effect of (inadequately dosed) etomidate. One more reason pharm induced intubation sans paralytic is far more dangerous.


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## NYMedic828 (Aug 18, 2012)

So then why is the maximum dose 20mg?

Shouldn't it be higher if this is the case? If its weight based anyway why should a 150lb person get the same does as a 300lb.


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## usalsfyre (Aug 18, 2012)

NYMedic828 said:


> So then why is the maximum dose 20mg?
> 
> Shouldn't it be higher if this is the case? If its weight based anyway why should a 150lb person get the same does as a 300lb.



Because your med control doesn't trust your paramedics?


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## Pavehawk (Aug 18, 2012)

That would be a good question to ask your medical director, though I suspect you know what the answer will be.


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## NomadicMedic (Aug 18, 2012)

Do you have the option to premedicate with versed? That's been shown to reduce the incidence of trismus.



usalsfyre said:


> Trismus is a side effect of (inadequately dosed) etomidate. One more reason pharm induced intubation sans paralytic is far more dangerous.



I was under the impression that trismus was a known side effect, no matter the dose.


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## MSDeltaFlt (Aug 18, 2012)

Every weight based dosing of etomidate I've ever seen is 0.3mg/kg.  My dry weight today is 224lbs.  That's 101.8kg.  Most providers will round me to 100kg.  0.3mg/kg X 100kg = 30mg.  So do you think 20mg would stop my breathing making me lose my gag, let alone prevent any trismus, for intubation?  I'll give you three guesses and the first two don't count.


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## MSDeltaFlt (Aug 18, 2012)

On top of that you had a cancer pt.  They are so used to narcotics and sedatives odds are the average dose wouldn't even touch them.


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## NYMedic828 (Aug 18, 2012)

n7lxi said:


> Do you have the option to premedicate with versed? That's been shown to reduce the incidence of trismus.
> 
> 
> 
> I was under the impression that trismus was a known side effect, no matter the dose.



I have the option if I request discretionary but the orders he gave me was 20mg of etomidate and 5mg of Valium if needed. We are only allowed to give the Valium after intubation has been established.


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## NYMedic828 (Aug 18, 2012)

Our protocols are actually

1-2mg of versed IV repeats of 1mg max of 5mg.

OR etomidate followed up with Valium after successful intubation.

Asking for the benzo first, and etomidate, would probably result in a no.



Granted we could give versed only and tube, but the standard here is almost always etomidate/Valium.


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## Smash (Aug 18, 2012)

NYMedic828 said:


> Our protocols are actually
> 
> 1-2mg of versed IV repeats of 1mg max of 5mg.
> 
> ...



Wow.  I don't know why your med director even bothers.  Etomidate is typically 0.3mg/kg as mentioned, midazolam is typically at least 0.1mg/kg, along with some fentanyl and that is when using muscle relaxants as well.

As usalsfyre says, it's just wrong to try to sedate and not paralyse then intubate.  And with those drug doses you are barely even sedating.  He or she should just remove the order altogether.  Drug assisted intubation needs to be done properly or not at all, in my opinion.  (Please note, this is not a dig at you, you probably didn't write your protocols)


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## NYMedic828 (Aug 18, 2012)

Smash said:


> Wow.  I don't know why your med director even bothers.  Etomidate is typically 0.3mg/kg as mentioned, midazolam is typically at least 0.1mg/kg, along with some fentanyl and that is when using muscle relaxants as well.
> 
> As usalsfyre says, it's just wrong to try to sedate and not paralyse then intubate.  And with those drug doses you are barely even sedating.  He or she should just remove the order altogether.  Drug assisted intubation needs to be done properly or not at all, in my opinion.  (Please note, this is not a dig at you, you probably didn't write your protocols)



Unfortunately NYC is not simply one medical director. We have around 10-15 of them working together.

Our etomidate is 0.3mg/kg but the max is 20mg. 9/10 times the patient meets criteria for the max dose.

This is only the second time ive had to facilitate intubation with medications and the first time it went very smoothly. 20mg etomidate, intubate, 5mg Valium. The only issue was, the 5mg Valium didn't keep her down after 10 minutes.

Reading this forum I realize how insanely low and strict our benzo/narcotics protocols are. Fentanyl has been utilized ONCE in all of FDNY. We have had it for a couple of years now...


Epocrates lists the sedation dose of versed @ 0.1-0.3mg/kg IV. This patient was roughly 70kg I'd say so that's 7-21mg of versed. Massively more than our orders are written. Each medic carries 20mg worth though so we have 40mg worth at any given moment.


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## MSDeltaFlt (Aug 18, 2012)

Smash said:


> Wow.  I don't know why your med director even bothers.  Etomidate is typically 0.3mg/kg as mentioned, midazolam is typically at least 0.1mg/kg, along with some fentanyl and that is when using muscle relaxants as well.
> 
> As usalsfyre says, it's just wrong to try to sedate and not paralyse then intubate.  And with those drug doses you are barely even sedating.  He or she should just remove the order altogether.  Drug assisted intubation needs to be done properly or not at all, in my opinion.  (Please note, this is not a dig at you, you probably didn't write your protocols)



Why would you paralyze your sedated pt if they stop breathing and lose their gag?  Rather the opposite is true.  You should never paralyze without sedation.


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## NYMedic828 (Aug 18, 2012)

MSDeltaFlt said:


> Why would you paralyze your sedated pt if they stop breathing and lose their gag?  Rather the opposite is true.  You should never paralyze without sedation.



I have been told concious paralyzation is one of the scariest things you can do to someone. I can only imagine the feeling of not being able to feel but knowin what is going on to some degree.

But I don't think Smash meant it that way. I think what he is stating is that sedation, without paralytics to follow, is poor practice. I don't see anywhere that he implied paralyzing a patient who is already past the point of needing to be paralyzed to facilitate intubation. I think he meant it as a general statement to properly executing intubations. Unfortunately here in NYC, we do not carry succs or rocu, and with the massive body of medics in NYC, and the lowest common denominator being incompetent and abundant, we never will.


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## usalsfyre (Aug 18, 2012)

MSDeltaFlt said:


> Why would you paralyze your sedated pt if they stop breathing and lose their gag?  Rather the opposite is true.  You should never paralyze without sedation.



Mike, I respect your opinion pretty highly, but I'm going to have to disagree. I'll give the paralytic simply to keep from triggering a gag in the middle of laryngoscopy and ending up with an aspiration event.

I've also had one airway that was "crash" enough the patient got rocc pre-intubation and midaz post.


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## FLdoc2011 (Aug 18, 2012)

usalsfyre said:


> Mike, I respect your opinion pretty highly, but I'm going to have to disagree. I'll give the paralytic simply to keep from triggering a gag in the middle of laryngoscopy and ending up with an aspiration event.
> 
> I've also had one airway that was "crash" enough the patient got rocc pre-intubation and midaz post.



Wait, you'll paralyze and not sedate?


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## FLdoc2011 (Aug 18, 2012)

http://emcrit.org/podcasts/paralytics-for-icu-intubations/

Some good info and a friendly debate on the use of paralytics for intubations in the ICU.


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## NYMedic828 (Aug 18, 2012)

FLdoc2011 said:


> Wait, you'll paralyze and not sedate?



I believe he is implying he would sedate, and even if gag reflex is surpressed still administer the paralytic to ensure it does not cause any complications during the procedure.


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## jwk (Aug 18, 2012)

MSDeltaFlt said:


> Why would you paralyze your sedated pt if they stop breathing and lose their gag?  Rather the opposite is true.  You should never paralyze without sedation.



Never say never.  An unconscious patient doesn't necessarily need sedation.  You can always add midazolam after the tube if you need it.  If you have an awake and alert patient, that's different.  Sedation is the nice thing to do.

As far as the trismus - tonic/clonic movements are quite common with etomidate.  That may have been what you were seeing.  I never use etomidate for procedural sedation - only for induction and always with paralysis.  Because of questions and problems regarding adrenal suppression with etomidate, many of us have abandoned it's use in the OR altogether.   

And BTW, there's a nationwide shortage of etomidate.  Sounds like some of you use it like water.  No wonder I don't have any in the OR, even if I wanted to use it.


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## NYMedic828 (Aug 18, 2012)

So, to sum up my original question,

Trismus 2nd to etomidate is NOT all that uncommon?

Is the cause due to improper dosing of etomidate, or does any dose have potential to cause it depending on the patient?

What are my options once it occurs having only versed and valium at my disposal? Insert a nasal airway and BVM for the remainder?


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## NomadicMedic (Aug 18, 2012)

I read it was a common side effect (+/- 15%). I'm on my phone, so I can't find the study. 

I was told, anecdotally, by a CRNA that a very slow push may negate the tendency for trismus. 

In my limited experience i've found that the paralytic works to quickly make the patient flaccid. However, since you don't have sux and you can't pretreat with Versed, you're SOL.


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## NYMedic828 (Aug 18, 2012)

Was this the study?

http://www.ncbi.nlm.nih.gov/m/pubmed/12087322/


I figured SOL was the answer I would get. It's a shame. 

None the less, it was a good learning experience that apparently after asking around many of my co-workers have never seen.

Side note, when we pushed the etomidate an otherwise unconscious patient threw his arms up violently over here his for about 3 seconds which made something feel wrong to begin with.


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## jwk (Aug 18, 2012)

NYMedic828 said:


> Was this the study?
> 
> http://www.ncbi.nlm.nih.gov/m/pubmed/12087322/
> 
> ...



So much fun when they do that.  Honestly, I never saw this all that much when etomidate was first released years ago.  Now, it seems like I see it most of the time.


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## NYMedic828 (Aug 18, 2012)

jwk said:


> So much fun when they do that.  Honestly, I never saw this all that much when etomidate was first released years ago.  Now, it seems like I see it most of the time.



Are you referring to the arm movement? I was tempted
to tell ZOMBIEEE!!!


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## usalsfyre (Aug 18, 2012)

FLdoc2011 said:


> Wait, you'll paralyze and not sedate?



I have, once. An unconscious, trismused patient, falling sats, and difficulty bagging. It was either push the rocc or cut. Crash airways are one of the emergency airway algorithms.


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## Handsome Robb (Aug 18, 2012)

NYMedic828 said:


> So, to sum up my original question,
> 
> Trismus 2nd to etomidate is NOT all that uncommon?
> 
> ...



It's anecdotal but from talking with two of my coworkers that used to work in a system that used etomidate but not paralytic had issues with it.  One said it never happened while the other said every time he gave it the patient locked down.

If things are real bad you could always nasally intubate them but that's going to be tough in a patient with a depressed or no respiratory effort and the ER doc may not be too happy with you.  I guess in the worst case scenario you could potentially create an unable to intubate/unable to ventilate scenario and have to jump to the bottom of the algorithm and cut. 

Again anecdotal but the guy from the aforementioned conversations said he'd do an NPA, maybe two and just bag.



usalsfyre said:


> I have, once. An unconscious, trismused patient, falling sats, and difficulty bagging. It was either push the rocc or cut. Crash airways are one of the emergency airway algorithms.



Sux and an apology? With a hefty dose of versed afterwards would the retrograde amnesia help or is that just a myth. I feel like I read somewhere that you can't count on the retrograde amnestic affects of versed.


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## MSDeltaFlt (Aug 18, 2012)

People all around this forum and others can quote you the onset down to the minute five or take 3, maybe 4,72, seconds.  Yet in all my years I haven't seen one practitioner willing to wait the full aloted time for the sedation to take effect.  They always go straight to the paralytic.

Maybe I didn't explain myself adequately.  But if you sedate your pt and they stop breathi.g and lose their gag reflex, then why use a paralytic?  I have asked this question over and over until I was blue in the face.  And not one single solitary soul has ever not once answered it directly.

I guess they don't want to continuously assess their pt and the efficacy of their treatments.  I guess all they want to do is to "get that tube" and move on.


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## usalsfyre (Aug 19, 2012)

MSDeltaFlt said:


> Maybe I didn't explain myself adequately.  But if you sedate your pt and they stop breathi.g and lose their gag reflex, then why use a paralytic?  I have asked this question over and over until I was blue in the face.  And not one single solitary soul has ever not once answered it directly.



I'll go ahead and answer directly. If I knock out the skeletal muscles associated with vommitting I have far less to worry about if for some reason I activate the gag reflex.

RSI was developed for intubating the non-NPO patient safely. The paralytic is about preventing puking.


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## Merck (Aug 19, 2012)

This discussion is missing something - context.  We're speaking of intubation like they're all the same when nothing could be further from the truth.  Are paralytics always needed ASAP - no.  Can things be done well with just sedation - sure.  Are any two the same - not really.  I'll propose 3 cases:

#1.  38 female pulled from a fire, conscious, stridorous, facial/neck/trunk burns, sooty, etc.  Approach to airway if any?  SpO2 92%.  Bonus question - other consideration?

#2.  67 male emphysemic, increasing SOB x 1/7, no relief with puffers, tachypneic, tripod, LOC decreasing, low tidal volume?

#3.  26 male drunk, fell 15 feet from an upper balcony on to concrete.  Isolated head trauma, GCS 1,1,3.  Blood in airway, C-spine obviously an issue.


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## 8jimi8 (Aug 19, 2012)

What is your other consideration for the airway burn? Is Ett not the definitive treatment prior to edema closing her trachea?


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## NYMedic828 (Aug 19, 2012)

Huh? Where did burns come into play?


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## MSDeltaFlt (Aug 19, 2012)

Merck said:


> This discussion is missing something - context.  We're speaking of intubation like they're all the same when nothing could be further from the truth.  Are paralytics always needed ASAP - no.  Can things be done well with just sedation - sure.  Are any two the same - not really.  I'll propose 3 cases:
> 
> #1.  38 female pulled from a fire, conscious, stridorous, facial/neck/trunk burns, sooty, etc.  Approach to airway if any?  SpO2 92%.  Bonus question - other consideration?
> 
> ...



Now this is more to my point.  There are definitely exceptions to every rule, especially with regards to airway burns where you have one shot at ETT before you have to cut.  It irks me to no end when I have a med control who write blanket protocols leaving out any room for clinical judgement.


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## NYMedic828 (Aug 19, 2012)

go figure I had basically the same job today...

20mg etomidate 5mg Valium.

Successful this time. Went with a VERY slow push on the etomidate and still had some Myoclonus but no trismus.


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## Merck (Aug 19, 2012)

I should apologize for hijacking the etomidate thread question and taking it on a bit of a tangent.  We don't use etomidate so my experience with it is limited.  From my reading you can expect myoclonus in up to 33% of patients and this shouldn't be unexpected or a concern.  The trismus is troubling and may be a sequelae of the myoclonus, assuming it isn't part of the underlying pathology for that patient (i.e. TBI).

One thing that bears mentioning with etomidate is that it has no analgesic properties - something I am always very cautious with when inducing unconsciousness/paralysis.

As for my tangent I brought up the 3 cases just to stimulate some discussion.  A one-size-fits-all approach to intubation is inappropriate and dangerous.  In my mind (feel free to disagree):

#1.  Our general approach to the consicous burn patient is, of course, intubation - preferably sooner rather than later.  But with this patient she is still breathing and maintaining muscle tone to help maintain her airway.  RSI is not our preferred approach here but rather one of heavy lidocaine spray/atomization and gentle use of ketamine (10, 20, 30, 40ish mgs at a time, depending on the pt) to gain pt compliance.  With these 2 therapies one can bring about a decent look for the cords either via DL or video laryngoscopy.  Once the tube is in place sedate/paralyze prn.

#2.  In my experience these patients will likely require very little to facilitate intubation.  There is likely a degree of CNS depression already due to hypercapnia and as such even a few mg of midazolam will generally be enough to perform DL and intubate with sedation/analgesia afterwards prn.  The advantage to perhaps paralyzing this patient would be to guard against vomiting (though not passive regurg) and maybe to increase a grade or 2 if visualization is or is expected to be difficult based on anatomy.

#3.  This patient will likely require RSI emergently.  There is likely no need for sedation but just the paralytic.  His GCS is already a 5 so I'd say he's relatively sedate.  In my practice I would likely use some high-dose fentanyl basically flushed with the paralytic (likely succ).  This will help to blunt a sympathetic response to laryngoscopy and 'may' help blunt an ICP spike but will likely have less hemodynamic effect.  Sedation other than this will increase the likelihood of hypotension - a poor idea in TBI.

My 2 cents


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## Doczilla (Aug 20, 2012)

NYMedic828 said:


> go figure I had basically the same job today...
> 
> 20mg etomidate 5mg Valium.
> 
> Successful this time. Went with a VERY slow push on the etomidate and still had some Myoclonus but no trismus.



Etomidate should definately be pushed like D50 every time. I didn't see it mentioned, but fast pushes can also cause projectile vomiting.


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## MSDeltaFlt (Aug 20, 2012)

Doczilla said:


> Etomidate should definately be pushed like D50 every time. I didn't see it mentioned, but fast pushes can also cause projectile vomiting.



Ah, almost forgot about "vomidate".


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## RocketMedic (Aug 25, 2012)

This has been quite educational. I really feel like I don't know a thing about RSI.

Question: With etomidate, how much is too much? The discussion of cancer patient's abnormally high tolerances for sedatives and analgesics makes me wonder if 0.3mg/kg is simply no longer an accurate benchmark.


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## Doczilla (Aug 25, 2012)

I doubt etomidate is used in specialty populations. They learned that lesson in burn units.


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## coolidge (Sep 23, 2012)

*after adm etomidate, allow myoclonus to dissipate*

April 2012 issue JEMS
After administration of etomidate, the lead paramedic allowed for any myoclonus and trismus to dissipate and attempted visualization of the patient’s airway using a Macintosh 3 laryngoscope blade. While his partner provided inline cervical stabilization, he noted a fair amount of blood in the hypopharynx and began aggressive suctioning in an attempt to visualize the patient’s vocal cords.


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## the_negro_puppy (Sep 23, 2012)

Although im not trained in sedation, intubation or RSI, it seems that if you are practising these in the field you really need broad enough protocols and be able to use clinical judgement with dosing etc to achieve the desired effects, considering the massive problems that can be encountered.

Seems like the NY ems has these protocols so they can say they are doing it, when really they are extremely restricted and the med directors would just prefer you drive them to hospital instead?:glare:


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## Christopher (Sep 24, 2012)

NYMedic828 said:


> So we had a respiratory failure with presumed aspiration this morning 2nd to vomiting. (stage 4 lung CA, no DNR/DNI.)
> 
> Unconscious, hypoglycemic, hypoxia sat in the low 80s. Normotensive, normal sinus.
> 
> ...



Half-*** RSI is not RSI, hence the problem encountered with using etomidate alone.


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## VFlutter (Sep 24, 2012)

Merck said:


> #1.  38 female pulled from a fire, conscious, stridorous, facial/neck/trunk burns, sooty, etc.  Approach to airway if any?  SpO2 92%.  *Bonus question - other consideration?*



Hyperkalemia? Don't push that Succ

Edit: I do not think that would really be an issue immediately post burn


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## Doczilla (Sep 24, 2012)

Only if the burn is greater than 24 hours old. Getting an airway takes precedence over MAYBE (or not at all with a new burn) raising their serum potassium by .5 meq/ml


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## Christopher (Sep 24, 2012)

Doczilla said:


> Only if the burn is greater than 24 hours old. Getting an airway takes precedence over MAYBE (or not at all with a new burn) raising their serum potassium by .5 meq/ml



Or just use roc @ 1.2 mg/kg and obviate the need for succ.


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## NYMedic828 (Sep 24, 2012)

the_negro_puppy said:


> Although im not trained in sedation, intubation or RSI, it seems that if you are practising these in the field you really need broad enough protocols and be able to use clinical judgement with dosing etc to achieve the desired effects, considering the massive problems that can be encountered.
> 
> Seems like the NY ems has these protocols so they can say they are doing it, when really they are extremely restricted and the med directors would just prefer you drive them to hospital instead?:glare:



That's because our providers are mostly complete morons.

If I was our medical director I wouldn't even allow people to start IVs.


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## NYMedic828 (Sep 24, 2012)

Our RSI stands for "Really Substandard Intubation."


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## Doczilla (Sep 24, 2012)

Poor guy. I'm gonna send you a care package.


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## rmabrey (Sep 24, 2012)

Sure would be nice to have Etomidate, We've been out for 5 months. All we have to play with is Versed. no protocol to give versed and Vec without Etomidate


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## usalsfyre (Sep 24, 2012)

rmabrey said:


> Sure would be nice to have Etomidate, We've been out for 5 months. All we have to play with is Versed. no protocol to give versed and Vec without Etomidate



There's so, so many levels of fail here....


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## NYMedic828 (Sep 24, 2012)

usalsfyre said:


> There's so, so many levels of fail here....



We have been out of etomidate as well.

Now they expect us to intubate with only versed or valium to facilitate. I'm just going to BVM them to the ER.


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## Doczilla (Sep 24, 2012)

NYMedic828 said:


> That's because our providers are mostly complete morons.
> 
> If I was our medical director I wouldn't even allow people to start IVs.



I bet there isn't a national ketamine shortage...


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## 911taxi (Oct 1, 2012)

Our protocol states per medical director,  Lido 1mg/kg for suspected closed head injury, followed by .03 mg/kg Etomidate for sedation/induction, followed by Succs 1mg/kg for paralysis. Pt is then maintained sedation with 2.5-5mg versed q10 and Fentanyl 1-3mcg/kg titrated to effect. If you miss the tube after three attempts automatic King airway, if you don't have confirmed Capnography wave form throughout procedure, you butt is mine. So far we have had great results with DAI!!!


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## mreaves16 (Oct 14, 2014)

It was the etomidate that caused the jaw clenching, this article explains it perfectly  emsworld.com/article/11176478/ems-airway-management


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## tpchristifulli (Oct 15, 2014)

I would just really get good at nasal intubations


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## Carlos Danger (Oct 15, 2014)

Etomidate causes myoclonus. The most commonly cited mechanism is disinhibition of the subcortical structures that suppress extrapyramidal motor activity. This appears more common (and probably more severe) when the etomidate is pushed quickly, probably due to distribution of the drug to the subcortical structures _before_ distribution to the cortex. This effect is not entirely different from the dystonic reactions sometimes seen with promethazine and metoclopramide.

The same thing happens with propofol occasionally. It is less common and less severe, probably at least in part because propofol is always pushed slowly.

Jaw rigidity is simply a manifestation of the myoclonus. When it happens, the masseter muscle probably is not the only one that is rigid, it's just the only one that you notice.


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## Shrimpfriedrice (Oct 18, 2014)

NYMedic828 said:


> So then why is the maximum dose 20mg?
> 
> Shouldn't it be higher if this is the case? If its weight based anyway why should a 150lb person get the same does as a 300lb.


The max dose for etomidate is 40mg not 20mg. This was changed check out your GOP


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## Handsome Robb (Oct 18, 2014)

Pretty sure he went to suppression over a year ago.


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## Nova1300 (Oct 19, 2014)

I feel like stoking the fire with opinion today, since this site is pretty slow...

Overall, etomidate is a garbage drug with very little, if any, hemodynamic benefit over other induction agents.  

Ketamine is a far superior prehospital induction agent.  

Your medical directors put it in the protocols because they don't understand it. 


I hope it goes the way of Xigris.


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## Carlos Danger (Oct 19, 2014)

Nova1300 said:


> Your medical directors put it in the protocols because they don't understand it.



I don't think they don't understand etomidate, I think they don't understand ketamine.

Also, while I know there's a convincing argument for why ketamine is a better option than etomidate, I think there's still a decent argument for etomidate in prehospital RSI. Ketamine does have some considerations that many folks would simply rather not deal with, at least not in the absence of the need for an agent that causes an SNS discharge.

IME....the large majority of prehospital RSI's that I've done were in head injured patients who were normo- or hypertensive, and giving an agent that increases MAP and CBF simply wasn't necessary. The laryngoscope does a fine job of that in many cases.

At the end of the day, I don't think either has been shown clearly superior to the other. If I went back to flying, I'd prefer to have both available.

I'm very interested in hearing why you think etomidate is such a lousy drug.


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## Nova1300 (Oct 21, 2014)

So, the pro arguments for ketamine -
Given your screen name, Im sure you are well aware of ketamine's benefits, so I wont delve too much into those.  However, we also know that in the presence of controlled ventilation there is little to no increase in ICP from ketamine.  And to be honest, in critically ill patients (who are catecholamine depleted) you are likely to see a hypotensive response after ketamine just as you do the other induction agents, which is probably attributable to the unopposed myocardial depression  normally offset by the catechol surge.  There is more emerging evidence that ketamine is, in fact, neuroprotective and it is actually becoming more common as a therapy for refractory status epilepticus. 

Etomidate - is gross.  And you can argue back and forth about the adrenal suppression and increased mortality with its use, but my issues with the drug are more practical.  Etomidate is a potent pro-emetic drug. And a lot of these patients remain nauseated for days after a single dose.  Though it does not seem to induce seizures, there is definitely a generalized epileptiform discharge on the EEG with its use.  And I can even forgive the myoclonus, the  long-lasting nausea, the potential adrenal suppression and the literature (albeit very soft) about increased mortality.  But to be honest, in my anecdotal experience, I actually see just as much hemodynamic instability with it vs. the other induction agents.  And this is in critically ill patients, the population to which this drug is targeted !!


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## Carlos Danger (Oct 21, 2014)

I would not use etomidate in an elective case for the reasons you mention, but I have used it many times prehospital and don't recall ever seeing hypotension result, save for those really sick patients whose pressure was going to drop no matter what you did. Perhaps ketamine would have worked better in those cases. I have much less experience with ketamine for induction.


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## FiremanMike (Oct 28, 2014)

We have both ketamine and etomidate with the option for either, however ketamine is to be used in bronchospasm patients.


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## Ralph (Aug 21, 2020)

MSDeltaFlt said:


> He wasn't sedated enough.  He needed more.


Generally trismus/masetter spasm isn’t a result of inadequate sedation, but more a result of to rapid of a push.  Etomidate should be pushed 30-60secs unless immediately followed by a paralytic..


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## ffemt8978 (Aug 21, 2020)

Holy thread revival, batman.


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