Thread subject: NEPI :: Induction agent for RSI

Posted by imron on 09-11-2008 22:17
#4

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)
[url]http://nepi.emergencymedicine.in/more/EmergencyIntubations.pdf[/url]

Click below to view the abstract published in Academic Emergency Medicine
[url]http://www3.interscience.wiley.com/cgi-bin/fulltext/119819491/PDFSTART[/url]


- Dr. Imron Subhan Cool

Edited by imron on 09-11-2008 22:28