Bozeman WP, Young S, (University of Florida, Jacksonville, FL; Baptist/St. Vincent's Health Services, Jacksonville, FL)IntroductionAdvanced airway management techniques, including medications, are routinely used in prehospital settings. In the authors' helicopter transport service, the rapid-onset anesthetic has been used for several years to facilitate endotracheal intubation. They report their experience with etomidate as the sole agent used to promote intubation, without paralytics.Patients and findingsThe 2-year experience included 50 patients receiving etomidate to facilitate endotracheal intubation during air transport. In 44 of these, etomidate was the sole agent used. The intubation success rate was 89%, with the remaining 11% of intubations being unsuccessful. Sixteen percent of the intubations were considered difficult, requiring 3 or more attempts or repeated doses of etomidate. The mean etomidate dose was 0.5 mg/kg. Eight patients vomited, but there were no cases of aspiration. Three patients had trismus or clenched jaws, which precluded successful intubation. One child had seizure-like activity after intubation.ConclusionsEtomidate may be used on its own to facilitate endotracheal intubation in the field. However, this approach is recommended only when rapid sequence intubation techniques with paralysis are contraindicated or undesirable.CommentAs with most studies of this type, there was no randomization or comparison with another agent or with placebo here; the air medical service simply implemented etomidate, to see what would happen. On the “plus” side, only 1 of the 50 patients demonstrated myoclonic, seizurelike activity. It is generally taught that etomidate frequently leads to this type of muscle activity unless it is used along with a neuromuscular blocker. This small study suggests that this is not a particularly common problem. On the “minus” side, intubation was difficult or impossible in almost one third of the patients studied.The author of an accompanying editorial stresses the hazards of paralyzing patients in the field and seems to hint that adding a neuromuscular blocker only if intubation cannot be accomplished with etomidate alone might be prudent.1 He notes that paralytics generally add minimal muscle relaxation when an appropriate degree of sedation has already been obtained. Although this may be true during a controlled nonemergency intubation in the ED, the time and effort needed to obtain this level of sedation often are just not practical in the field. Furthermore, not all emergency physicians would agree with his assertion that “… anyone who has ever struggled to intubate a combative GI bleeder lying on the floor near the last stall in the restroom in the back of a bar understands that muscle relaxation is rarely essential for successful tube placement.” Anecdote does not equal data: we need randomized, controlled trials to determine the optimal pharmacologic adjuncts for field airway management. Bozeman WP, Young S, (University of Florida, Jacksonville, FL; Baptist/St. Vincent's Health Services, Jacksonville, FL) IntroductionAdvanced airway management techniques, including medications, are routinely used in prehospital settings. In the authors' helicopter transport service, the rapid-onset anesthetic has been used for several years to facilitate endotracheal intubation. They report their experience with etomidate as the sole agent used to promote intubation, without paralytics. Advanced airway management techniques, including medications, are routinely used in prehospital settings. In the authors' helicopter transport service, the rapid-onset anesthetic has been used for several years to facilitate endotracheal intubation. They report their experience with etomidate as the sole agent used to promote intubation, without paralytics. Patients and findingsThe 2-year experience included 50 patients receiving etomidate to facilitate endotracheal intubation during air transport. In 44 of these, etomidate was the sole agent used. The intubation success rate was 89%, with the remaining 11% of intubations being unsuccessful. Sixteen percent of the intubations were considered difficult, requiring 3 or more attempts or repeated doses of etomidate. The mean etomidate dose was 0.5 mg/kg. Eight patients vomited, but there were no cases of aspiration. Three patients had trismus or clenched jaws, which precluded successful intubation. One child had seizure-like activity after intubation. The 2-year experience included 50 patients receiving etomidate to facilitate endotracheal intubation during air transport. In 44 of these, etomidate was the sole agent used. The intubation success rate was 89%, with the remaining 11% of intubations being unsuccessful. Sixteen percent of the intubations were considered difficult, requiring 3 or more attempts or repeated doses of etomidate. The mean etomidate dose was 0.5 mg/kg. Eight patients vomited, but there were no cases of aspiration. Three patients had trismus or clenched jaws, which precluded successful intubation. One child had seizure-like activity after intubation. ConclusionsEtomidate may be used on its own to facilitate endotracheal intubation in the field. However, this approach is recommended only when rapid sequence intubation techniques with paralysis are contraindicated or undesirable. Etomidate may be used on its own to facilitate endotracheal intubation in the field. However, this approach is recommended only when rapid sequence intubation techniques with paralysis are contraindicated or undesirable.
Read full abstract
Nov 7, 2023
Henry E Wang + 10
Open Access