Rapid Sequence Intubation (RSI): Etomidate For RSI

Mechanism of action

Etomidate is GABA receptor agonist that blocks neuroexcitation and induces unconsciousness.

Etomidate is imidazole-derived which is sedative-hypnotic that is a commonly used induction agent for RSI.

Dose

The most common dose used is 0.3 mg/kg IV
- An adjusted body weight is recommended in morbidly obese patients.

Onset

15-45 seconds

Duration

3-12 minutes

Adverse effects

Myoclonus can occur 25-63%
- Can be mistaken for seizure activity
Pain on injection
- Thought to be due to diluent propylene glycol
Adrenal Suppression
- Inhibits corticoneogenesis and 11β-hydroxylation which may decrease cortisol and aldosterone levels, resulting in prolonged suppression.
Etomidate causes reduction in intraocular pressure (IOP).

Impact on Hemodynamics

Blood Pressure (BP)	Heart Rate (HR)	Cardiac Output (CO)	Intracranial Pressure (ICP)
↔ No Impact	↔ No Impact	↔ No Impact	↓ Decrease

Etomidate Impact on Hemodynamics

Comment

Etomidate has no analgesic effects.

Gold standard induction agent for RSI

Literature Review

Author, year	Design/ sample size	Intervention & Comparison	Outcome
Lyons, 2015	Cohort study/ n=261	Etomidate+ Succinylcholine (Group 1) vs Fentanyl+ ketamine+ rocuronium (Group 2)	Significantly better laryngeal views with fentanyl/ketamine/rocuronium group 100% first attempt intubation with fentanyl/ketamine/rocuronium group ↑ post-intubation MAP+ HR with etomidate + succinylcholine
Bruder, 2015	Cochrane Review	Etomidate Midazolam Propofol Ketamine	There was no difference in mortality, hospital LOS, duration of ventilation, and duration of vasopressors Etomidate associated with ↑ ACTH and ↓ in cortisol level
Tekwani K, 2010	RCT/ n=122	Etomidate 0.3 mg/kg vs Midazolam 0.1 mg/kg	No significant differences in median hospital LOS (9.5 vs 7.3 days), ICU LOS (4.2 vs 3.1 days), In-hospital mortality ( 26% vs 43%), or ventilator days
Jabre P, 2009	RCT/ n=469	Etomidate 0.3 mg/kg vs Ketamine 2 mg/kg	No difference in intubating condition, SOFA score, 28-day mortality, Ventilator free days, vasopressor support, or GCS

ACHT= Adrenocorticotropic hormone; GCS= Glasgow Coma; HR= Heart Rate; MAP= Mean Arterial Pressure; RCT= Randomized Controlled Trial; Scale; SOFA= Sequential Organ Failure Assessment;

Rapid Sequence Intubation (RSI) Masterclass

Introduction

Quizzes

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