November 11, 2022

Dear Colleagues,

Welcome back to EMS-I’s Pharmacy Phriday. Over the next two weeks, the focus of these articles will include the medications Etomidate and Succinylcholine that are used in UH’s protocol for Rapid Sequence Intubation (RSI). 

Before continuing with this week’s medication review, we wish to point out an error in the Responsoft Application of the UH protocols that has been brought to our attention. The listed indications for the use of Fentanyl within the Pharmacology section in the application are incorrect and should read:

1. Severe pain management

2. ACS/STEMI

3. Abdominal Pain

4. Isolated Trauma

Sorry for any confusion, and thank you to those who notice and report these types of errors so that they can be corrected in future additions. Now, on to our focus for this week.

Any time a medication is used to facilitate intubation, it is referred to as medication-assisted or drug-assisted intubation. In the UH “adult airway” protocol, Ketamine is mentioned as a consideration for use to sedate a patient experiencing pain that the paramedic is planning to intubate. This would be an example of a medication-assisted intubation and is permitted for use by any paramedic. 

When a neuromuscular blocking agent is used in the procedure, this is an example of RSI. It is a procedure approved for use only by a department and paramedic who have received training and medical control approval prior to the call. Paramedics not only receive initial training but periodic competencies to ensure a proper skill level.

RSI is a two-part pharmacological process, including a sedative followed by a paralytic. (It is worth noting that RSI should always follow basic airway management and maneuvers, including oxygenation, another “medication” crucial to the procedure. See the UH Adult Rapid Sequence Intubation (RSI) protocol.)  Etomidate is a medication often used to induce anesthesia and is the approved sedative in the UH protocols. It is considered to be one of the safer sedatives used in RSI. Ketamine is an alternative as the induction agent and can be considered in cases of trauma. 

Etomidate is a short-acting hypnotic sedative used for the induction of anesthesia prior to the intubation attempt.   The onset of the medication is rapid, with an onset of 10-20 seconds, and a short duration, approximately 3-5 minutes. Adult dosing is 0.2 – 0.3 mg/kg given IV or IO. The usual dose is 20 mg. Once Etomidate has been administered, it is followed by a paralytic agent, which will be discussed in the next issue of Pharmacy Phriday.

As we close this week’s article, we will draw your attention to today’s date. November 11th is Veterans Day. Veterans Day was originally known as Armistice Day and was first observed in 1919 following WWI to honor the heroism of those who died in the country’s service. It was observed on November 11 as the end of fighting between the Allied nations and Germany occurred at the 11th hour, of the 11th day, of the 11th month in 1918. Following WWII and the Korean War, Armistice Day was officially changed to Veterans Day to honor American Veterans of all wars.

We thank all our Veterans for your service and encourage others to recognize any Veteran you may know or meet today! And look for the “green lights” in your community as part of a nationwide effort to demonstrate appreciation and support for our American Veterans. See the following link for further details.

(https://www.naco.org/resources/signature-projects/operation-green-light-veterans)

Till next week, stay safe.

Sincerely,

The UH EMS-I Team

University Hospitals