Etomidate ---> Jaw clenching? Coincidence?

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NYMedic828

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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?
 

NomadicMedic

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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

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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.
 

jwk

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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.
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

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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!!!
 

usalsfyre

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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.
 

Handsome Robb

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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?
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.

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

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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.
 

usalsfyre

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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.
 

Merck

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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.
 

8jimi8

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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

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Huh? Where did burns come into play?
 

MSDeltaFlt

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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.
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

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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.
 

Merck

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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
 

Doczilla

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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.
 

MSDeltaFlt

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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".
 

RocketMedic

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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.
 

coolidge

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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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