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Induction agent for RSI
I have been looking at what could be an ideal induction agent for performing an emergency department or pre-hospital RSI.
Has anyone got any strong likes or dislikes to one agent over the other?
Or, do you choose your induction agent based on the clinical setting?
If you have to choose only one agent (Assuming that you'd want to minimise clinical errors by cutting on the choice) when introducing this into your departmental policy, which induction agent would you choose?
etomidate. for prehosp as well as ED RSI. best hemodynamically stable agent
ketamine best for status asthmaticus.bad for head injury pts. causes halluciantions. etomidate very expensive. best for all pts becoz of no change in hemodynamics.propofol may be used for trauma pt. fentanyl less sedative but good analgesic. mida and thiopental not for trauma pt
In the past 3 yrs, EM physicians in our dept have performed more than 1000 intubations. About 70% recieved sedation or RSI. And almost all were with MIDAZOLAM (Good safety profile, water soluble in 5ml [1mg/ml] vials, can be used immediately, cheap, no storage problems unlike propofol & thiopentone, reduced dose in compromised patients still gives adequate sedation)

ETOMIDATE - Not available

PROPOFOL - Expensive, Cannot be stored. Risk of infection of contents if not discarded

THIOPENTONE - Needs reconstitution - takes time. Crystallizes if stored. Causes hypotension. Inadvertent arterial injection = end of story for the EM resident!

We found excellent use for midazolam, especially in an academic center where there are junior EM residents. Can be used in almost all patients even if there is another drug of choice. The 15-20mmHg drop in systolic pressure is the only thing to be remembered. Occurs in full dose for RSI (0.1mg/kg). Can be prevented by reducing the dose by 25-50% and by 1-2 min injection instead of a 10sec IV push. The low cost of Midazolam + Succinylcholine combination allows its use in busy EM depts where patients may have financial contraints. Where decision to admit will be dependent on paying capacity. Where intubation will be indicated before this can be done. Helps us to keep the outpatient bill to minimum if the patient is taken away LAMA/DAMA.

We do use ketamine and morphine, but in highly selected cases. Ketamine for bronchospasm and morphine in pulmonary edema related intubations. The random anesthetist who manages to find a case to intubated in our ED just loves propofol. So we stock it only for them!

Our dept had presented a paper titled PROSPECTIVE & DESCRIPTIVE STUDY OF EMERGENCY ROOM INTUBATIONS at INTEM-2006, New Delhi. We had closely looked at intubations in this study. For academic purposes of the NEPI community as well as upcoming Indian emergency depts, we have put a PDF version of the presentation online.

Click below to view the full PDF version (Needs Adobe Acrobat)

Click below to view the abstract published in Academic Emergency Medicine

- Dr. Imron Subhan Cool
Edited by imron on 09-11-2008 22:28
Looks like Etomidate and Midazolam are the favourites so far...
Any more out there with their preferences??
Shajoo, is it a strict no no for Ketamine in the head injured patient? What about the polytrauma patient (including head inj) who has low BP? Would you still avoid Ketamine for induction?
Apart from the negatives that Imron pointed to, would its effect in Adrenocorticoid activity not discourage its use (mainly the septic patients!!!). Also it is not licensed for use in children (according to the manufacturer)...
Imron, agree that Etomidate is not available or too expensive for use in India. Are there no other options? Why not Ketamine?
Don't you think that Midazolam does not particularly hold the BP, more so in the already shocked patient?? I did go through your study article... but is there any better evidence to support or refute its use as an ideal induction agent in our context...
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