Etomidate and Trauma

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DB

My comments between yours!

> To the etomidate folks:
>
> I feel that etomidate has no real use in trauma. My reasons are:
>
> 1) Unpredictable myoclonic/hebiphrenic/catatonic reactions which can
> result in airway compromise or lack of patient control
Not clinically significant if sux is used
> 2) Adrenocortical suppression (and although it is alleged, I use the
> Cheney 1% rule)
A given, but not yet shown to increase MORTALITY
> 3) Expense (not yet an issue in the US, but if ObamaCare takes hold,
> budget-limited care...)
No comment - reasonably cheap in South Africa
> 4) Ease of administration (40 mg in 20 cc solution in a glass ampule? Give
> me a break.)
For most adults that equates to one amp at 0.3mg/kg. I accept glass is not
good, but maybe the supplier could change it.
> 4) Ketamine is the best brain eraser for the trauma victim, hands down.
Ketamine is a good 2nd choice in my book. It can RAISE the BP and
therefore INCREASE bleeding in the damage control type patient.
>
> If I am to manage a trauma victim's airway in the ED, I do so in the
> following way:
>
> First, I shut off the frontal lobe with ketamine. This is the kindest
> thing I can do.
> Ketamine does not affect the brain stem (blood pressure, respiration), and
> it renders mammals perceptually decerebrate (dissociative anesthetic).
> Next, I wage a receptor war:
> a) an Opiod for mu, kappa, et. al. receptors: 1 - 4 mg hydromorph (always
> treat pain)
> b) a GABA drug: 1 - 4 mg lorazepam (to treat anxiety, sedate, prevent
> seizures, provide muscle relaxaion, interject amnesia)
> c) an H1 blocker: 25 - 50 mg`diphenhydramine (to mitigate any
> histamine-releasing reaction)
> d) an H2 blocker: 20 mg famotidine (to prevent me from getting a Curling's
> or Cushing's ulcer)
Both c & d not likely to be the best choice - see the latest EAST
guideline - Sucralfate as good as H-blockers and PPI
> e) a neuromuscular blocker: 10 - 20 mg vecuronium (if necessary, depending
> upon the situation).
VEC is a bad drug to use for RSI - too long action onset in standard dose
and increased side-effects with high dose
>
> If I am not worried about hypovolemia, then I occasionally use propofol in
> the place of  ketamine.
Acceptable
>
> After that (if the night is good), they should be the anesthetist's
> problem....
>
> Come on - argue with me. I need stimulation.
>
> DB
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>
Tim Hardcastle
South Africa

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