Would like to add a few more points as a response to your question Jeff.
The situations where Etomidate would be ideal would be RSI in a
hemodynamically unstable head injured patient. It preserves hemodynamics
better than Thiopental and has the same
rapidity of action. Combined with Sux, one can obtain intubating
circumstances in less than a minute, which is an unbeatable combo!!
Unfortunately, it is still significantly more expensive than Thiopental
here. The latter being dirt cheap. Also, because of the reported adrenal
suppression effect, I would also avoid it in RSI for "sepsis".
For the relative contraindications to paralysis in RSI, that Harvey talked
about, i.e. potentially difficult airway, my preference is to use a
sedative like midazolam & fentanyl with Cetacaine LA spray prior to
intubation. In this scenario, I would much rather use a REVERSIBLE agent &
BTW, transiently with Sux, by virtue of its depolarization action, there is
diffuse muscular spasm. This is not "true" masseter spasm. The most common
reason for this is premature attempts at intubation prior to full effect. I
have to tell the resident's to wait for 20-30 seconds for complete
relaxation before attempting. This may seem like eternity at times!! True
masseter spasm from malignant hyperthermia is important to keep in mind. It
is persistent and is accompanied by a rapid rise in temperature which is
the tip off.
As far as pretreatment with small NMB doses, it will indeed prevent this
initial muscle spasm but will NOT prevent MH. I am not a fan of this
strategy because it adds another intervention which delays the RSI and
seems counter to what one is trying to achieve.
Incidentally, our anesthesiologists and PICU folks have abandoned sux in
favour of Rocuronium, which works as fast as the former but has a 30-40
minute duration of action.
just my $0.02......
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