Etomidate ---> Jaw clenching? Coincidence?

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the_negro_puppy

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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:
 

Christopher

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

VFlutter

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#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

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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
 

Christopher

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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

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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

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Our RSI stands for "Really Substandard Intubation."
 

rmabrey

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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
 

usalsfyre

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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

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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.
 

911taxi

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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!!!
 

mreaves16

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

Carlos Danger

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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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Handsome Robb

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Pretty sure he went to suppression over a year ago.
 

Nova1300

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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.
 

Carlos Danger

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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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