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Tue Aug 19 10:31:35 BST 2008

Sorry to sound fierce! I must say that I feel that the evidence is hardening
against etomidate. The best quality evidence is in the septic patient, as
Tim Hardcastle has already said, but my take on this is to use the
precautionary principle - I can't tell which patient is going to end up in
the ITU with sepsis syndrome when they hit the ED, and when other better
drugs are available to achieve the same early outcome (anaesthesia) why not
use them? That is what I meant by evidence earlier on. I used to use
etomidate extensively before we knew about its problems, and it was very
good for 'cardiovascular stability' in the short term so we used it a lot on
the pump patients.

The evidence on the contraindication to ketamine in head trauma is
interesting. You need to go back to the early 1970s for the first report
when ketamine was being evaluated. I can't lay my hands on the physical
paper at this moment, but I believe it to be  Sari A, Okuda Y, Takeshita H.
The effect of ketamine on cerebrospinal fluid pressure. Anesth Analg. 1972
Jul-Aug;51(4):560-5. 

They were using ketamine to induce people with known brain tumours for
resection who already had their ICP measured. Ketamine caused a rise in ICP
but it was abolished by IPPV. It certainly is being used with a recent
(unfortunately it looks as though there has been too much subgroup analysis)
study on TIVA:  

Grathwohl KW, Black IH, Spinella PC, Sweeney J, Robalino J, Helminiak J,
Grimes J, Gullick R, Wade CE.Total intravenous anesthesia including ketamine
versus volatile gas anesthesia for combat-related operative traumatic brain
injury. Anesthesiology. 2008 Jul;109(1):44-53.  

There seems to be no difference and certainly no adverse outcome with
ketamine.

More importantly, a good study recently was designed to address the problem
in neurosurgical patients and found that there was NO evidence that ketamine
(admittedly S+, not the usual recemic mix we all use) caused a rise in ICP.

Schmittner MD, Vajkoczy SL, Horn P, Bertsch T, Quintel M, Vajkoczy P, Muench
E.Effects of fentanyl and S(+)-ketamine on cerebral hemodynamics,
gastrointestinal motility, and need of vasopressors in patients with
intracranial pathologies: a pilot study.J Neurosurg Anesthesiol. 2007
Oct;19(4):257-62.  

I have spent a good 25 years trying to convince the emergency community to
use ketamine - as a single agent in the field, please, to prevent the apnoea
that benzodiazepine co-administration can cause - and when you are in the ED
you can switch to another iv agent if you wish. However, I warn again
against the slightly potty idea of mixing it with propofol.

If you are worried about emergence phenomena then add some midazolam as the
patient wakes. Most importantly, allow the patient to wake naturally, as the
bad dreams seem to have been associated with brutal wake-up regimes.

Best Wishes,

Rowley. 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of neil mullen
Sent: 19 August 2008 00:49
To: Trauma & Critical Care mailing list
Subject: Re: trauma-list Digest, Vol 62, Issue 12

Yes, I was taken aback by the ferocity of blueflightmedic's statement about
etomidate and trauma, and another one debunking the standard teaching that
ketamine should not be used in patients with possible increased ICP.  Being
a simple ED physician, I get far too little feedback about the patients I
admit, but this is the first I've time I've heard the blanket statement that
etomidate is CONTRAINDCATED.  As for ketamine, I've not read of any
definitive science one way or the other, although I've read many (many)
times that it is contraindicated and very rarely that it is safe. 
Blueflightmedic said he's debunked this myth multiple times in the post - I
must have missed those postings.  Perhaps, just one more time...?

Neil Mullen, MD

--- On Fri, 8/15/08, Robert Smith <rfsmithmd at comcast.net> wrote:

From: Robert Smith <rfsmithmd at comcast.net>
Subject: Re: trauma-list Digest, Vol 62, Issue 12
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Date: Friday, August 15, 2008, 11:22 AM

Tim,

Thanks. Was he the one that was suggesting etomidate in trauma = death  
( we're traveling and I don't have the posts on my laptop). I was  
confused about this as we very often use this as an induction agent.

Rob

On Aug 15, 2008, at 1:21 PM, dr.tchardcastle at absamail.co.za wrote:

> Rob
>
> Article focus is septic shock and does not really address trauma to
> the
> extent originally indicated. I have made a suggestion about a trauma
> focussed article to Rowley off-list and if he is interested will  
> post to
> the list next week.
>
> Tim Hardcastle
> Trauma Surgeon
> IALCH / Univ. KZN
> Durban
> South Africa
>
>> Any chance you could cut and paste the article?
>>
>>
>> On Aug 14, 2008, at 5:14 PM, Blueflightmedic wrote:
>>
>>> Good recent article in the EMJ from Bernard Foex and Hamish
Thomson:
>>>
>>>
http://emj.bmj.com/cgi/content/extract/25/8/469?maxtoshow=&HITS=10&hits=10&R
>>> ESULTFORMAT
>>>
=&fulltext=etomidate&andorexactfulltext=and&searchid=1&FIRSTINDEX
>>> =0&sortspec=relevance&resourcetype=HWCIT
>>>
>>> I apologise for the huge URL.
>>>
>>> Best Wishes,
>>>
>>> Rowley.
>>>
>>> -----Original Message-----
>>> From: trauma-list-bounces at trauma.org 
>>> [mailto:trauma-list-bounces at trauma.org
>>> ]
>>> On Behalf Of Dominik Krzanicki
>>> Sent: 14 August 2008 12:38
>>> To: trauma-list at trauma.org
>>> Subject: RE: trauma-list Digest, Vol 62, Issue 12
>>>
>>>
>>>
>>>
>>>
>>> Date: Wed, 13 Aug 2008 22:04:44 +0100From:
"Blueflightmedic"
>>> <trauma at emergencyunit.com>Subject: RE: trauma-list Digest,
Vol 62,
>>> Issue 7 -
>>> sedation and NICE	guidance.To: "'Trauma &amp;
Critical Care mailing
>>> list'"	<trauma-list at trauma.org>Message-ID:
>>> <000201c8fd88$3798f5d0$0901a8c0 at vaio>Content-Type:
text/plain;
>>> charset="windows-1256" There is ample evidence that even
a single
>>> shot of
>>> etomidate increasesmortality in trauma. It is absolutely 
>>> contraindicated. I can see the evidence that single dose etomidate 
>>> has an increased mortlity
>>> rate in septic patients - unless seondary steroid supplementation
is
>>> administered. Continuous infusion is also pretty clear...not sure
if
>>> I can
>>> see the overwhelming evidence for mortality following a single
>>> shot in
>>> trauma - could you expand on that please?
>>> Dom Krzanicki Dr Dominik Krzanicki
>>> MBChB(Hons), MRCS (Eng), DIMC (RCSEd)
>>> StR Anaesthetics and Intensive Care
>>> Tel: +44 (0) 7801 118790
>>> E-mail: dominikkrzanicki at hotmail.com
>>>
>>> _________________________________________________________________
>>> Win a voice over part with Kung Fu Panda & Live Search   and  
100?s
>>> of Kung
>>> Fu Panda prizes to win with Live Search 
>>> http://clk.atdmt.com/UKM/go/107571439/direct/01/
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>>
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