Someone dislocated something the other day, so I asked for some etomidate.
This is my go-to med for conscious sedations (this new term, “procedural sedation & analgesia,” I don’t see ever catching on because it’s so much easier to say conscious than procedural). Usually this involves someone presenting with a bone pointing the wrong way. Etomidate in, and five minutes later they wake up with everything realigned.
So great for patients, and fun for me too. After I give it, I ask the patients to count back from 100. Usually they’re good until 94 or so, then it’s nine-tee-threeeeeeee, their voice trailing off like a record slowly coming to a stop. Or their eyes glaze over and just before they go out they say “oh my god!” I always wonder what they are seeing/feeling to make them say this, they never can remember after waking up.
This is, incidently, the only medicine that I have to push through the IV myself. Our nurses have been given the ok to go over the risks of etomidate, obtain consent to give it, set up all of the monitoring equipment, get the suction and bag-valve mask ready, place the IV, and take responsibility for monitoring the patient until it’s worn off. But going so far as to push the etomidate through the IV? Well, that’s just a little too reckless. Nevermind that I give meds about as gracefully as I handled riding a bike for the first time. Nurse can you give this IV epinephrine to this dying patient? No problem. Thrombolytics? Head bleed schmed bleed. Dilaudid? Adenosine? Levophed? Yes, yes, and yes. But trying to give a nurse a syringe full of etomidate is like trying to give a vampire a cross made out of garlic. They know it’s ridiculous too, of course, and I understand that they have to follow protocol. No matter how stupid it might be.
Anyways, since I give it myself I was drawing some up the other day. We have these new plastic cannulas that we use in lieu of needles to draw up meds. When I took the cannula out it left a little hole in the rubber stopper of the etomidate bottle, and since I had pushed a bunch of air in there a lot of it came squirting out onto my gloveless hands. After a few seconds I thought to myself “hmm can this soak through my skin? Maybe I better wash it off.” As I started towards the sink I felt my heart drop down into my stomach and my legs get really weak. It only lasted for a second or so and I felt better by the time I reached the sink, where I rinsed it off without further incident.
So I’m wondering did I almost do a conscious sedation on myself? Or was this all psychosomatic? I really couldn’t find any literature on this either way. All the same, I think I’ll be gloving up from now on.
March 12, 2008 at 6:33 pm
Just curious. What’s your dosing? Do you also use etomidate for RSI?
March 12, 2008 at 6:36 pm
0.2mg/kg for CS, 0.3mg/kg for RSI
March 12, 2008 at 7:39 pm
I hope it’s alright if a curious non-medical professional asks a [stupid] question.
What is the logic behind having patients “count backwards from 100″ rather than say…forward from 1?
Is there some reason that it has been done that way, and continues to be done that way, rather than chance or coincidence? (like info that it provides you or something)
Just curious.
I never really thought about it, I do it that way because that’s how I’ve always seen it done. We could have folks say the alphabet too, there’s nothing special about counting down.
March 12, 2008 at 8:24 pm
Ever do the 0.6 mg/kg for RSI, for head injuries?
Can’t say I’ve ever heard of that.
March 12, 2008 at 8:47 pm
I too love Etomidate. I find that even with small doses (like 0.1 mg/kg) I can do many procedural sedations. They’re not completely out, but for fast procedures they’re out enough to not remember anything.
I used Propofol quite a bit in residency and that was good too, but I had more problems with apnea with that then I seem to have with Etomidate. Oh, and our nurses can’t push Propofol but can push Etomidate, so that’s another benefit of the latter.
I agree way less worrying about the airway. I guess you don’t get quite as good muscle relaxation as you do with propofol, but I don’t think it makes a difference clinically.
March 12, 2008 at 8:48 pm
At our hospital, we can’t push a lot of meds, but Etomidate is not one of them. I push that and succinylcholine all the time during intubations.
I guess they changed the terminology from “conscious sedation” to “procedural sedation” because I have NEVER seen a reduction of a dislocation in a patient who wasn’t completely snoring. I mean, they have got to be OUT like a light.
That’s the other crazy thing I didn’t mention in the post: the nurses can push etomidate for intubating, but not for conscious sedation. Go figure.
March 13, 2008 at 11:21 am
It’s MODERATE sedation at our place. We too, can give Etomidate but not Propofol IV push. Propofol drips are OK, go figure.
March 13, 2008 at 4:40 pm
OK, now you have me curious enough that I’m going to try it on myself next time I have an intubation.
Excellent! Thank you for your contribution to science.
March 13, 2008 at 7:42 pm
we can not push the first dose of propofol, but we can push every dose after that….go figure
March 13, 2008 at 8:58 pm
Our nurses can push Propofol, but not Etomidate. There are other things, like Ketamine, that they can push, but the physician has to physically be in the room during the push.
We also have a stupid rule that only cardiologists can push metoprolol due to some resident pushing it on an already bradycardic patient that resulted in a code a few years ago. To get around this, we just “run it in over 2 min” in a small bag of saline rather than an actual “IVP”. Silly stuff.
March 14, 2008 at 5:29 am
I’m a big fan of etomidate too, but one of the places I work doesn’t stock it, so I use brevital there.
Ketamine is my all-time favorite, but I’ve never used it in an adult because of the fear-mongering about emergence reactions. I’m tempted though.
I’ve always wondered if the emergence reaction stuff is overstated. Why don’t you try it and let me know how it goes.
March 15, 2008 at 2:15 pm
Regarding that “plastic cannula”—We use a brand that has a blue “dart” in the clear plastic cannula. Once you withdraw the clear plastic tip…the blue dart stays in the rubber stopper. No holey no squirty!
‘Course technically you can’t use it on a multi-dose vial…(but you can slip the plastic cannula back over the dart and extract more med….just don’t tell anybody I told ya!)
Steve
March 16, 2008 at 6:50 pm
I can push etomidate, sux, vec, IVP propofol and do propofol drips. Who wants to touch me?
March 17, 2008 at 8:44 pm
K is used plenty in adults in Africa. Actually, though technically it isn’t a deep enough sedative, we did C-sections with it when we got a bad batch of spinal.
No problem with emergence reactions in my admittedly limited experience, but hey, just adding a voice.
As for your etomidate story, the mental picture of what COULD have come next was brilliant! Thanks for the giggle.
March 20, 2008 at 1:23 pm
Ketamine, isn’t that used in veterinary medicine as well? I remember hearing about teenagers and drug abusers breaking into veterinary offices here in Florida a few years ago to get their hands on the stuff.
Never realized it was used in human medicine as well.
Come to think of it, is there a big difference in the medicine used on animals and humans, or can most of them be used on either?
March 21, 2008 at 6:49 pm
I remember using Ketamine during undergrad research to sedate the rats before surgery. Pretty entertaining watching a rat come out of sedation.
March 23, 2008 at 1:42 pm
I too squirted myself with Etomidate at an RSI refresher on friday – felt a quick rush of light-headedness and then was fine… makes ya wonder, doesn’t it?
March 27, 2008 at 12:17 pm
We use etomidate in the field (transport ambulance service)as an induction agent prior to RSI. I haven’t been lucky enough to use it yet. However I haven’t heard of anyone having problems with it. While researching the med for our protocol update, I did chuckle when I came across a web page stating that the most common post-op side effect was vomiting, causing the med to be refered to as “e-vomi-date”.
On a side note, I do know that you can accidently squirt succinylcholine in your eye (through the same mechanism as other posts) and not paralyze yourself. Thank god! Although, I wonder if that is dose dependent?!…
April 3, 2008 at 8:13 pm
I’ve accidentally squirted etomidate in my mouth (long story involving a broken draw needle), I also got a little light-headed, but it passed quickly.
July 21, 2008 at 5:00 pm
Has anyone every heard of a ketamine-like emergence reaction with etomidate?
August 28, 2008 at 6:39 pm
I just got home from the local ER with my son who dislocated his elbow on the monkey bars at school. They reduced it without any problems using etomidate. I’m a L&D RN and hadn’t seen the use of that one…but it was AWESOME! He woke up and went right back to watching Spongebob Squarepants as if nothing had happened…made some comment about how he felt like he’d just gotten up from a good, long nap. Fine with me if that’s how he wants to remember it. Ha Ha
September 30, 2008 at 10:06 am
I just used Etomidate last night at work, the doc was inserting an arterial line and wanted it as sedation to a patient who was on levophed. This guy was 165 kilos! I did the math and it was going to involve me drawing up more than a vial of this stuff so i had to check with 3 other nurses and then the doc as to the safety of this dose, he settled with 30 mg. This guy was out for hours, glad he was already on a vent.
As for propofol, i really like it because it wears off so quickly, makes for a quick “sedation vacation”.
Better nursing through pharmacology..LOL