Trial Use of New Procedure in Rockland

[helicopper 1,050]

Rockland continues to be proactive and tries another new technique in the field. Interesting article - best of luck to RPS and their patients!

Rockland paramedics start trial run of drug used in ER

By JANE LERNER

THE JOURNAL NEWS

(Original publication: May 26, 2007)

NANUET

Starting this weekend, several local paramedics will be carrying something new when called to emergencies.

It's a drug called "etomidate," and doctors and emergency service workers hope it will help save lives.

"This is going to significantly help us establish an airway and stabilize patients who are seriously injured," said Ray Florida, director of the Nanuet-based Rockland Paramedic Services.

The medication - normally used only by physicians in hospitals - is a fast-acting anesthetic that relaxes patients so they can undergo painful procedures, such as having a breathing tube put down their throats.

Rockland Paramedic Services is starting a six-month study to see if the drug can safely be used in the field.

The organization is among the first in the region to experiment with use of etomidate by trained paramedics outside of a hospital. Paramedics, along with emergency-room doctors from Nyack and Good Samaritan hospitals, will study its use in the field to see if it helps save lives.

Other local paramedics will be watching closely as well.

"I believe that if their study comes out favorably, use of etomidate will be written into protocols throughout the region," said Nelson Machado, quality improvement coordinator for the Hudson Valley Regional Emergency Medical Services Council, an agency that oversees paramedic services in six counties, including Rockland, Putnam and Orange.

At least once a week, paramedics treat a patient who has severe enough injuries that he or she cannot breathe, Florida said.

The study is starting at the beginning of the warm-weather months, when emergency service workers traditionally see an increase in injuries and accidents.

Rockland Paramedic responded to 21,419 calls in 2006, Florida said. He estimated that 3,500 or so involved patients who required intubation.

"Maintaining an airway is one of the most crucial things we do," said paramedic Michael E. Murphy, who is leading the study for Rockland Paramedic Services.

The paramedics have received special training on using the drug.

Unlike many powerful sedatives, etomidate does not paralyze a patient.

"It's a hypnotic drug," Machado said. "When you're on it, you don't know what is being done to you."

Murphy predicted it would be most useful in patients who had suffered serious head injuries.

That's because those patients often experience a reflex reaction that causes them to clench their jaws - making it impossible for emergency workers to open their mouths to insert breathing tubes.

Emergency-room physicians have long used etomidate to help stabilize trauma victims, said Dr. Michael Lippe, director of the emergency department at Good Samaritan Hospital.

If paramedics are unable to create an airway in a severely injured patient before getting to an emergency room, they have to use a mechanical bag to help the patient breathe. That's not the most effective way to treat patients with serious injuries, Lippe said.

He expects that patients treated with etomidate who have breathing tubes inserted will fare better once they arrive at the hospital for treatment.

"The bottom line is that it's a very safe drug," Lippe said. "And it makes patients more comfortable."

health|county's paramedics lead the way

Reach Jane Lerner at jlerner@lohud.com or 845-578-2458.

[INIT915 1,119]

According to the article, more than 16% of RPS patients required intubation. Does that sound a little high to anyone else?

[helicopper 1,050]

According to the article, more than 16% of RPS patients required intubation. Does that sound a little high to anyone else?

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If that is 16% of ALS calls, it sounds reasonable. 16 of 100 ALS calls require intubation - not extraordinary.

16% of ALL calls? That may be a little high.

[NYMedic37 22]

Etomidate is also being used in NY City with good results but lasts only a short time so it tends to get used in conjunction with Ativan or Versed to maintain sedation and pain control.

Paul

[Oswegowind 17]

Etomidate has been used at Empress for 4 or 5 years now...Didn't realize it wasn't everywhere! That ish is awesome...knocks em out good!

[WAS967 97]

Wow. I thought RPS already was using the full RSI protocol. Good to know. Etomidate SHOULD be making it's way into the regular ALS protocols in WC in the next revision (as opposed to special procedures). Stay tuned.

[Guest]

Sounds like a very proactive step on behalf of RPS - they have always seemed to be doing things "right." If it gets added to the HV protocols, i know it will be a welcome edition for many.

Edited May 26, 2007 by 66Alpha1

[201/65 94]

If I'm not mistaken, Mobile Life is the only RSI approved agency in the HV Region right now.

[Guest paramedico987]

I love me some etomidate!

Now if they'd just make it in a dart gun for the less cooperative patients we'd be all set!

[Oswegowind 17]

I love me some etomidate!

  Now if they'd just make it in a dart gun for the less cooperative patients we'd be all set!

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LMAO...you'd better register that before someone makes millions off of it!

[STAT213 332]

Oh boy...

Etomidate is a great drug. Its a non barbiturate hypnotic with rapid onset and short duration. Here's the kicker...the research is quite clear that using sedatives ALONE to achieve, or attempt to achieve intubation lead to more complications. Either RSI or don't. They passed on the idea of MAI up here. Many places do it. If it ends up in your drug box, please don't view it as the end all and be all. Etomidate is a great drug, when mixed with succinylcholine. Be very careful using it alone.

[WAS967 97]

Etomidate is a great drug. Its a non barbiturate hypnotic with rapid onset and short duration. Here's the kicker...the research is quite clear that using sedatives ALONE to achieve, or attempt to achieve intubation lead to more complications. Either RSI or don't. They passed on the idea of MAI up here. Many places do it. If it ends up in your drug box, please don't view it as the end all and be all. Etomidate is a great drug, when mixed with succinylcholine. Be very careful using it alone.

Could you tell us more about the down sides? I'd love to know what complications it causes. (Seriously, not being facetious). I really hope we get some kind of MAI down here as I've had plenty of calls where we could have genuinely used it, and when you have a 20+ minute transport to the ER, it needs to be done sooner than later. There is talk about adding Etomidate to the WC protocols as an MAI measure since a lot of the docs are still skeptical to allowing medics to paralyze someone when they don't intubate as often as they want them to. RSI is good in areas where the medics are dropping tubes every other week, but in areas up north, where you maybe intubate once a month at most, I can understand their skepticism.

Edited May 31, 2007 by WAS967

[WAS967 97]

Interesting info from upstate relating to Etomidate vs Diazepam:

Objective . To report the preliminary experience of the Central New York emergency medical services (EMS) region with etomidate for prehospital facilitated intubation. Methods . Prospective recording of all intubations (facilitated and nonfacilitated) was completed during the first six months of the etomidate protocol, from January 1 to June 30, 2000. These results were compared with retrospective comparison data obtained for an 18-month period from stored documented prehospital care reports (PCRs), a period when diazepam was used for facilitated intubation. Results . During the study period, 343 (84%) of 409 attempted intubations were successful. Of these, 24 facilitated intubations (using etomidate) were attempted (all on breathing, agitated patients), and 19 (79%, CI 63%-95%) were successful. Eighteen of these (95%) were intubated successfully on the first attempt. The median age of the patients requiring intubation was 70 years (range 14-90), and 60% were female. There were no reported incidences of vomiting, broken teeth, or bleeding. The region's prior 18-month experience using diazepam for facilitated intubation resulted in ten (23%, CI 11%-36%) successful intubations of 43 facilitated intubation attempts. Conclusions . Preliminary data suggest increased rates of success for facilitated intubation using etomidate, when compared with diazepam, with most intubations successful on the first attempt. Limitations of this study include a small sample size and self-reporting of airway data by paramedics.

From http://www.ingentaconnect.com/content/tand...10?crawler=true

[WAS967 97]

On the not-so-flip-side, here is a study from France that seems to indicate no difference in efficacy between Etomidate and Benzodiazapines. With this in mind, I would say Etomidate would make a better choice since 1) you could give it on standing order - Versed you can't since SEMAC won't allow any controlled substance on standing order aside from Valium for status and 2) some agencies just don't carry enough Versed to be effective (my primary agency only usually carries 4mg).

Study objective: The primary objective of this study is to compare the intubation success rates of etomidate and midazolam when used for sedative-facilitated intubation, without paralytics, in out-of-hospital adult patients. Methods: This prospective, double-blind, randomized trial was conducted with 2 ground out-of-hospital advanced life support systems (ALS); all patients aged 18 or older who required out-of-hospital sedative-facilitated intubation were eligible for participation. The ambulances were stocked with blinded numbered syringes containing either 7 mg of midazolam or 20 mg of etomidate. No paralytics were used. If sedation was not achieved with the study drug, medics could request additional sedation from a medical command physician; only midazolam or diazepam were available outside of the study. Results: One hundred ten patients were enrolled in the study; 55 patients received midazolam and 55 patients received etomidate. The 2 groups were similar with regard to age, sex, initial vital signs, and reasons for intubation or sedation. The overall intubation success rate was 76% (95% confidence interval [Cl] 68% to 84%); 75% (41/55) for midazolam (95% Cl 64% to 86%) and 76% (42/55) for etomidate (95% Cl 65% to 87%). There was also no difference in incidence of hypotension, number of intubation attempts, or perceived difficulty of intubation. Additional sedation was requested almost equally for the 2 groups: 14 patients in the midazolam group and 12 patients in the etomidate group. A benzodiazepine was successful for rescue of a failed etomidate intubation 10 of 12 times (83%; 95% Cl 62% to 100%). When used for rescue of failed midazolam intubations, benzodiazepines were effective in only 5 of 14 (36%, 95% Cl 11% to 61%) attempts. Conclusion: There were no observed differences between midazolam and etomidate in sedation-facilitated intubation success rates; we could not fully evaluate global outcomes of these agents or the sedative-facilitated intubation strategy itself.

[Guest paramedico987]

Could you tell us more about the down sides? I'd love to know what complications it causes. (Seriously, not being facetious).  I really hope we get some kind of MAI down here as I've had plenty of calls where we could have genuinely used it, and when you have a 20+ minute transport to the ER, it needs to be done sooner than later. There is talk about adding Etomidate to the WC protocols as an MAI measure since a lot of the docs are still skeptical to allowing medics to paralyze someone when they don't intubate as often as they want them to. RSI is good in areas where the medics are dropping tubes every other week, but in areas up north, where you maybe intubate once a month at most, I can understand their skepticism.

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Etomidate is an online medical control option in the standard Westchester protocol [#2] for advanced airway... you've just got to get it in the drug box [likely has to be approved by the medical director or something like that]

This should be kept in mind by anyone who uses RSI... In the event that you have a patient with renal failure [gosh, when do renal patients ever get sick enough for a tube?] you wouldn't want to give sux since is causes a spike in the serum potasium level and their kidneys may not be able to deal with it fast enough if at all.

Edited June 2, 2007 by paramedico987

[Guest alsfirefighter]

I'm in an agency where we were told we were going to get Etomidate and RSI but it hasn't happened.

a lot of the docs are still skeptical to allowing medics to paralyze someone when they don't intubate as often as they want them to.

I have always and still think this is a BS statement. This is why you also have an additional airway management device with you. Combitube, king airway or whatever. This is also why you are suppose to have QA/QI and be cleared to perform special procedures. If you can't cut the mustard you don't get to carry it and you shouldn't be able to carry it. If this is the case...hell lets toss all ET tubes and laryngoscopes out the windows.

[WAS967 97]

Tommy,

I agree with you. It is BS, but unfortunately it's the truth. Ask half the MC docs out there what they think about giving Paramedics RSI. The opinions will astound you. Hell, our very own Paramedic director is at the forefront of not allowing us to do RSI. Is it any wonder we haven't seen it materialize?

[STAT213 332]

WAS asked about the downsides of Etomidate. There really aren't any (well one). Its a fabulous drug. It has little or no cardiac side effects, no effect on blood pressure. It is extremely short acting. Repeat dosing has been shown to have some negative adrenal effects. Thus, its recommended to be given only once.

My mentioning of downsides was specifically related to a MAI protocol. While the whole concept of give it, and if you can't secure the airway bag mask ventilate them seems like a good idea, it is a very dangerous five minutes. Especially when you take a breathing patient and make them non breathing and are unable to control their airway. Both RSI and MAI are inherently risky procedures, but its been pretty well proven that MAI is the more dangerous of the two.

So. What to do? The really messy ones are facial trauma, trismus, and the like. Do you prohibit use of MAI in those situations.. You see where this is headed, it is the slippery slope, and it is why the med control docs are so nervous about letting us do it. Here in NH we have an RSI protocol, but no MAI protocol. They even go so far as to say those allowed to do RSI can't do MAI. (With the same drugs) Weird, huh? Or is it. MAI is dangerous territory. The medical control doc for the largest service in NH is dead set against his troops using MAI/RSI. Why do you think this is? Its about control and education.

Rob