Conscious Sedation:Etomidate

Rapid Induction for Intubation

Program Goals

• Background on Intubation• Current Methods and Practices• New Medications and Theories• Patient Selection• Difficult Airway

Background

• Endotracheal intubation is considered the “Gold Standard” for airway management. Currently only Oral and Nasal Intubation are available for use.

Oral Intubation

• Orotracheal intubation is the most commonly used means of securing the airway in the adult patient.

• It can prove difficult in awake patients or patients with an intact gag reflex.

• Success rates for oral intubation with an acutely dyspnic patient are low.

• It can be difficult to secure the airway of a breathing, conscious patient.

Nasal Intubations

• Blind Nasotracheal Intubation is an under utilized skill, that is difficult to be proficient in.

• It has a high occurrence of trauma and infection.

• It is a blind procedure.• Patient must be breathing.

New PracticesEtomidate• Etomidate is a short acting hypnotic.• When utilized, Etomidate will relax the

patient enough to produce intubation conditions within 10-15 seconds.

• Etomidate has a relatively short half life of 10 minutes.

• Proven efficacy of 80%.

Etomidate is NOT

• A paralytic• An analgesic

Etomidate

• Contraindications:• Known Hypersensitivity

to Etomidate• Under the Age of 10.

Precautions

• Possible hypoventilation or apnea in overdosage.

• Myoclonus: Diffuse muscle contraction.• Pre-medicate with a Benzodiazepine

before administration of Etomidate

Side Effects

• Pain at injection site, try to use the antecubital fossa.

• Hypotension• Apnea• Tachycardia• Nausea and Vomiting

Etomidate

• Etomidate is not an analgesic, anticipate reflex hypertension and tachycardia.

• Not indicated to relax or reduce trismus or clenching of the jaw.

• You must assess the patient as a candidate for this procedure.

Clearing the Patient

• It is imperative that each possible patient receive a thorough examination for difficulty in intubation. Any patient found to be of high risk, or high degree of difficulty should not receive Etomidate.

MEDIC TUBES +T

• Mouth / Mandible• Excessive Weight• Deformity• Incisors• C-Spine

• Thyromental Distance

• Uvula• Burns• Emisis• Stridor• TRISMUS

Mouth / Mandible

• Measure the opening size of the mouth. Anything less than three fingers should be considered a potential problem

• Check to make sure the mandible is centered and free from deformity and fracture.

Excessive Weight

• Obese patients that have large necks and small chins can be very difficult to intubate.

• Be sure your patient has an adequate range of motion in their neck and lower jaw.

Deformity

• Inspect the face, neck, mouth, and oropharnyx for deformity, swelling, bleeding, or any potential problems.

Incisors

• Inspect the mouth and teeth for loose debris.

• Buckteeth may result in poor visualization.

• Check for dental appliances and remove any that can be.

C-Spine

• Inspect the neck, patients with short large necks can be difficult to intubate.

• If the patient is immobilized be sure to have in-line stabilization maintained.

• Remember it is more difficult to intubate someone in c-spine because the axis is not lined up correctly.

Thyromental Distance

• Measure the distance from the chin to the thyroid cartilage, anything under three finger widths can be a difficult intubation.

Protocol

1. Routine paramedic care2. Routine preparation for intubation3. Contact medical control for etomiate4. Administer 0.3 mg/kg IVP over 30 to

60 seconds5. Intubate6. Verify tube placement with third party

device

Post procedure

• Complete the etomidate survey and clip to the QI/QA hospital copy