Etomidate and Adrenocortical Insufficiency in the Trauma Patient

 

 
 
 

Keith Wesley, MD, FACEP | | Monday, December 29, 2008


Review of: Hildreth AN, Mejia VA, Maxwell RA, et al: "Adrenal suppression following a single dose of etomidate for rapid sequence induction: A prospective randomized study." Journal of Trauma. 65(3):573 579, 2008.

The Science

The administration of etomidate has been linked to subsequent adrenocortical insufficiency in non-trauma patients but has not been well studied in the trauma population. These researches enrolled 30 multiple-trauma patients and randomized them to either receive etomidate (18 E patients) and succinylcholine, or a combination of fentanyl and midazolam (12 FM patients) with succinylcholine for RSI. They then measured their serum cortisol levels four to six hours afterward and performed a cortisol stimulation test by administering ACTH.

The patients reportedly had similar degrees of trauma and were aggressively resuscitated. They followed their clinical course and found the following. The serum cortisol levels of the 18 E patients was significantly lower than the FM patients and failed to respond to ACTH as well as the FM patients. This would consistent with suppression of the adrenal cortex.

Clinically, the patients in the E group required longer ICU stays (6.3 days versus 1.5 days,p< 0.05), more ventilator days (28 versus 17,p< 0.01), and longer hospital stays (11.6 days versus 6.4,p< 0.01) compared to the FM group.

The authors conclude that the use of etomidate for RSI in trauma patients let to chemical evidence of adrenocortical insufficiency and may have contributed to the clinical findings listed above. In the text of the article, the authors make this statement: "In light of our study, we recommend that other drugs should be used as first-line agents for RSI in trauma patients."

The Street

Just when you thought you had a handle on the RSI issue, someone comes along and throws another wrench in the works. The concern for adrenal insufficiency is why we abandoned high-dose steroids for suspected spinal injuries. Although I don't contest the cortisol levels the authors obtained in this study, I do question their conclusions.

First, the treating physicians were not blinded to which patients were in which group. They knew who was adrenosuppressed. Did this affect their treatment? The E group received significantly more intravenous fluids, blood and blood products. The authors state the patients had similar brain and lung injury severity scores, but we should take notice that the overall injury severity scores were higher (26 versus 19). Although not statistically significant, this may be due to the relatively low overall sample size of only 30 patients and the fact that 60% of the patients were in the E group.

The authors attempt to theorize that the adrenocortical insufficiency may have somehow altered the physiology of the E group in some way as to require their need for a greater need for volume replacement, but they do not provide us any supporting evidence for this theory. I would feel more confident if I knew more about the specific injuries of both groups. The injury severity score is simply not specific enough for such a small study group to make such generalizations.

Although this article sparks my interest, I'm not prepared to eliminate etomidate from my protocols just yet. More study is warranted, and I would ask future authors to be prepared to provide more details about the patient injuries so that we can attempt to determine what if any impact adrenocortical insufficiency, as it relates to etomidate administration, plays in the trauma victim.




Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Airway and Respiratory, Research

 
What's Your Take? Comment Now ...

Featured Careers & Jobs in EMS

 

 

 

 

 

 

 

 

 

Get JEMS in Your Inbox

 

Fire EMS Blogs


Blogger Browser

Today's Featured Posts

 

EMS Airway Clinic

The Evolution of Civilian High Threat Medical Guidelines

How mass killing events have proven a need for new guidelines.
More >

Multimedia Thumb

Authorities Investigate Firefighters at Arizona EMS Call

Confrontation caught on video involving Glendale firefighters.
Watch It >


Multimedia Thumb

Radio Problems for New York Medics

Medic’s radio failed during a call with an armed patient.
Watch It >


Multimedia Thumb

AMR Prepares Ambulance for Ebola Patient

Patient preparedness in Oregon.
Watch It >


Multimedia Thumb

Oregon Department Revises EMS System

Bend brings in EMTs to meet growing demands.
Watch It >


Multimedia Thumb

Ottawa Shooting Incident

Solider is shot by gunman at national memorial in Ottawa.
More >


Multimedia Thumb

Life Link III Trauma Tactics Conference in Minnesota

Conference was designed to enhance the skills of providers of all levels, covering rescue and prehospital situations, to transport and in-hospital treatment.
More >


Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

Sneak peek of customizable run forms & more.
Watch It >


Multimedia Thumb

The AmbuBus®, Bus Stretcher Conversion Kit - EMS Today 2013

AmbuBus®, Bus Stretcher all-hazards preparedness & response tool
Watch It >


Multimedia Thumb

VividTrac offered by Vivid Medical - EMS Today 2013

VividTrac, affordable high performance video intubation device.
Watch It >


More Product Videos >