Etomidate for Procedural Sedation in the Emergency Department

Samuel M. Keim, MD, Brian L. Erstad, PharmD, FCCM, John C. Sakles, MD, Virgil Davis, MD

Disclosures

Pharmacotherapy. 2002;22(5) 

In This Article

Abstract and Introduction

Abstract

Study Objective. To review our experience with etomidate in nonintubated patients in the emergency department.
Design. A 2-year retrospective chart review of consecutive patients receiving etomidate for sedation.
Setting. Emergency department of a university-based teaching hospital.
Patients. Forty-eight patients who underwent painful procedures in the emergency department.
Measurements and Main Results. Demographics, dosing information, recovery times, and adverse events were abstracted using a standardized data collection form. Forty-eight nonintubated patients were sedated with etomidate. Mean age was 34 years (range 6-80 yrs); 38 were men and 10 women; two were children. The mean initial dose of etomidate was 13 mg. Adverse events occurred in 11 (21%) patients. None sustained any substantial morbidity as indicated by need for intubation, prolonged emergency department stay, or hospital admission.
Conclusion. Although controversial, etomidate holds promise as a potent sedative agent for patients undergoing painful procedures in the emergency department. A large prospective evaluation is needed to document the performance and complications of this agent.

Introduction

Emergency physicians frequently are required to provide sedation for urgent procedures in the emergency department. Conventionally, this has been accomplished with conscious sedation, in which patients maintain protective airway reflexes and have some response to verbal and painful stimuli. Because some emergency physicians mindfully have administered traditional and new drugs in a manner that provided more profound sedation than is achievable by conscious sedation, the practice of deep sedation has grown. Controversy has arisen regarding the degree to which protective reflexes are reduced or lost as sedation deepens.

Ideally, the agent chosen would provide the patient with adequate sedation for the procedure, have a brief duration of action, and be safe and easy to administer. Previously described is the administration of potent sedative hypnotic drugs such as propofol,[1] methohexital,[2] and ketamine[3] to provide brief deep sedation in the emergency department. Some specialists state that ketamine is unique in that it seems to offer deep sedation without the loss of protective reflexes.[3]

Etomidate, (R)-(+)-ethyl-1-(1-phenylethyl)-1H-imidazole-5-carboxylate, (Amidate, Abbott Laboratories, Abbott Park, IL) is thought to work at the g-aminobutyric acid receptor to produce hypnosis without analgesia. Most emergency physicians are familiar with etomidate for its function as a potent sedative during rapid-sequence intubation. When administered for this purpose, it provides brief deep sedation with minimal cardiovascular effects, a relative lack of respiratory depression, and probable beneficial effects on cerebral perfusion.[4,5,6,7,8] However, etomidate is similar to propofol and methohexital in that the protective airway reflexes may be lost briefly or significantly reduced. Of interest, aspi-ration during procedural sedation in the emergency department has not been reported in the medical literature and is thought to be uncommon.[9]

Etomidate has been administered as a sedative outside the emergency department for patients with cardioversion.[6,8,10] One report describes administration by nonanesthesiologists for testing automatic internal cardiac defibrillators.[6] Several reports describe administration of etomidate in the emergency department.[11,12,13,14,15,16,17] We describe its administration for procedural sedation in the emergency department of a university medical center. Given the controversy surrounding this function of etomidate, we make a special effort to discuss guidelines and policies developed at our institution for ensuring the most appropriate administration of this agent in the emergency department.

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