II. Precaution
- Procedural Sedation with Etomidate risks respiratory depression
- Monitoring is critical
III. Mechanism
- Imidazole derivative
- Sedation agent with minimal Analgesic effect
IV. Contraindications
- Hypersensitivity to Etomidate
-
Seizure Disorder
- Etomidate lowers the Seizure threshold and other agents are preferred
-
Sepsis (risk of adrenal suppression)
- Avoid more than single use (e.g. induction for RSI appears safe)
V. Indication
-
Procedural Sedation
- Indicated for ASA Physical Status Score 2 and 3
- Ketamine is usually preferred over Etomidate for sedation in children
- Historically agent of choice in adult Conscious Sedation
- Consider for sedation in hypotensive adult patient
- Otherwise Propofol is preferred adult Sedative due to greater efficacy and less Myoclonus than Etomidate
- Miner (2007) Ann Emerg Med 49(1): 15-22 [PubMed]
- Fracture or dislocation reduction
- Significant Wound Debridement
- Rectal Foreign Body
-
Rapid Sequence Intubation
- Most hemodynamically stable agent of induction medications
- Induction Agent of choice overall
- Specific scenarios in which it is especially preferred
- Trauma
- Congestive Heart Failure
- Hemorrhagic CVA with increased Blood Pressure
VI. Preparations
- Etomidate 2 mg/ml in 40 mg/20 ml prefilled syringe
VII. Dose: Induction prior to intubation (induction agent)
- Adult: 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) over 30-60 seconds IV
- Child: 0.2-0.3 mg/kg IV
- Ketamine may be preferred in children
VIII. Dose: Procedural Sedation
- IV: 0.15 to 0.2 mg/kg
- Repeat 0.05 mg/kg every 3-5 minutes as needed
IX. Pharmacokinetics
- Onset: Within 1 minute of IV dose
- Duration: 3-5 minutes (up to 15 minutes in some cases)
- Metabolized by liver
- Effect may be prolonged in liver failure
X. Safety
- Pregnancy Category C (but limited data in humans, but not generally recommended in pregnancy due to animal studies)
- No delay in Lactation
XI. Adverse Effects
-
Nausea or Vomiting on emergence from agent (>10%)
- Consider pre-treatment with Anti-emetic, or have one available
- As always with Procedural Sedation, have suction with catheter on and ready for use
-
Myoclonus or Muscle twitching (20-40% of cases)
- Typical duration 30-120 seconds
- Administer Etomidate slowly over 90 seconds
- Management
- Prevention
- Pre-treatment is generally not recommended
- Pre-treatment with Fentanyl, Midazolam or Magnesium Sulfate has been used
- Respiratory depression (in up to 15% of cases)
- More common when combined with Opioid Analgesics
- Responds to Supplemental Oxygen
- Positive Pressure Ventilation is rarely needed
- Adrenal suppression (impacts survival in Sepsis)
- Consider Ketamine as alternative in Sepsis
- Not Clinically Significant if used in single dose as induction agent for intubation
- Avoid in Sepsis for any longer use than brief
XII. References
- Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
- Kay (2015) Crit Dec Emerg Med 29(8): 11-17
- Brown (2005) Am Fam Physician 71:85-90 [PubMed]
- Vinson (2002) Ann Emerg Med 39:592-8 [PubMed]
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Related Studies
Definition (NCI) | An imidazole derivative with short-acting sedative, hypnotic, and general anesthetic properties. Etomidate appears to have gamma-aminobutyric acid (GABA) like effects, mediated through GABA-A receptor. The action enhances the inhibitory effect of GABA on the central nervous system by causing chloride channel opening events which leads to membrane hyperpolarization. |
Definition (MSH) | Imidazole derivative anesthetic and hypnotic with little effect on blood gases, ventilation, or the cardiovascular system. It has been proposed as an induction anesthetic. |
Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
MSH | D005045 |
SnomedCT | 387218008, 40429005 |
English | Ethomidate, Etomidate, 1H-Imidazole-5-carboxylic acid, 1-(1-phenylethyl)-, ethyl ester, (R)-, 1H-Imidazole-5-Carboxylic Acid, 1-((1R)-1-phenylethyl)-, Ethyl Ester, R-(+)-Ethyl 1-(1-phenylethyl)-1H-imidazole-5-carboxylate, etomidate (medication), sedatives etomidate, ETOMIDATE, Etomidate [Chemical/Ingredient], ethomidate, etomidate, Etomidate (product), Etomidate (substance) |
Swedish | Etomidat |
Czech | etomidát |
Finnish | Etomidaatti |
Russian | ETOMIDAT, ЭТОМИДАТ |
Japanese | エトミダート, エトミデート |
Polish | Etomidate |
Spanish | etomidato (producto), etomidato (sustancia), etomidato, Etomidato |
French | Étomidate |
German | Etomidat |
Italian | Etomidato |
Portuguese | Etomidato |
Ontology: Amidate (C0718463)
Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
English | Amidate |