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Etomidate and Trauma

Garth Melnick gmelnick at efn.org
Wed Aug 20 03:38:31 BST 2008


A few comments from the prehospital side of things:

I agree that the literature that's been presented here recently  
suggests some serious concerns for the use of etomidate in terms of  
adrenocortical suppression, and that needs to be addressed.

However, I have to take issue with some of your other thoughts and  
concerns...

With a fast-acting paralytic onboard (e.g. sux) there shouldn't be any  
problems secondary to etomidate in terms of compromising your airway  
and losing control of your pt. Etomidate is one of the better agents  
in terms of maintaining hemodynamic stability (though ketamine does  
sound promising, but I haven't heard of it being used much prehospital  
here in the western US). I have not had issues with ease of  
administration -- our etomidate is packaged in preloads just like code  
drugs and is very easy to administer.

Finally, the sequence of drugs you propose below may be appropriate in  
an ED environment, but is far too complex for a prehospital  
environment, with only one or two ALS providers on most scenes, and  
only 4-6 providers total. The folks whose airways we are controlling  
are generally the ones with the most emergent need (versus the ones  
who are intubated semi-electively in the ED) and so the simplest  
sequence of drugs is best.

Just a few thoughts from a humble paramedic...

Garth
NREMTP, etc

On Aug 19, 2008, at 1:17 AM, bensonblues at comcast.net wrote:

> 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
> 2) Adrenocortical suppression (and although it is alleged, I use the  
> Cheney 1% rule)
> 3) Expense (not yet an issue in the US, but if ObamaCare takes hold,  
> budget-limited care...)
> 4) Ease of administration (40 mg in 20 cc solution in a glass  
> ampule? Give me a break.)
> 4) Ketamine is the best brain eraser for the trauma victim, hands  
> down.
>
> 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)
> e) a neuromuscular blocker: 10 - 20 mg vecuronium (if necessary,  
> depending upon the situation).
>
> If I am not worried about hypovolemia, then I occasionally use  
> propofol in the place of  ketamine.
>
> 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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