Re: Sedation vs. sedation/paralysis

["Thomas P. Walsh" <tpwalsh@mindspring.com>]

Rick,

We too use Etomidate and I have had a couple of cases of myclonus
"clenching" down.
Our protocol is
Lidocaine 1.5 mg/kg,
.01mg/kg defasiculating Vecuronium
0.3mg/kg Etomidate
1.5mg/kg Anectine
After tube placement and confirmation heavier Vecuronium for continued
paralysis.

Sedation afterward is a FC choice of Versed,Fentanyl, Morphine or Ativan.
We tend to be big on Fentanyl and Versed and in combination works very
nicely.

Initially we were giving just Etomidate and if they went down and were
intubated great.  We have changed that to medical pt's only or potentially
nasty airways.  For head injured pt's we do a full RSI with the thought that
if you get in there with only Etomidate and they gag you just blew your
whole ICP protection idea.  I have personal thoughts on the Etomidate for
the few cases 2-3 of "clenchers" that I had.  WARNING : THIS IS Totally
andedotal.  I have thought the few times it has happened to me was due to
pushing the medication maybe a little too fast.  I have pushed it a little
slower with no issues so far. Luck or just really dumb luck I have no idea.
I throw it our there as a thought to ponder.  There is also some literature
out there somewhere about pretreating with Fentanyl 1mcg/kg prior to
Etomidate decreasing the incidents of myclonus.  I can not for the life of
me remember where (long shift last nite)  I will try to locate it for you.

Great drub in general and I recomend it highly.  It of course is not perfect
but it's way more helpful then it is a hinderence.  Please feel free to
email me privately if you have any other questions.

Tom Walsh
NREMT-P
Albany Medflight/Albany NY


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