Etomidate ---> Jaw clenching? Coincidence?

[NYMedic828]

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?

 

[MSDeltaFlt]

He wasn't sedated enough. He needed more.

 

[usalsfyre]

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

 

[NYMedic828]

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.

 

[usalsfyre]

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?

 

[Pavehawk]

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

 

[NomadicMedic]

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

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.

 

[MSDeltaFlt]

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.

 

[MSDeltaFlt]

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.

 

[NYMedic828]

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.

 

[NYMedic828]

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.

 

[Smash]

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.

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)

 

[NYMedic828]

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.

 

[MSDeltaFlt]

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.

 

[NYMedic828]

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.

 

[usalsfyre]

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.

 

[FLdoc2011]

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?

 

[FLdoc2011]

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.

 

[NYMedic828]

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.

 

[jwk]

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.