Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department

Objectives: Although etomidate is widely used for rapid sequence intubation (RSI), there is no consensus on the optimal induction agent and no prospective pediatric emergency department (ED) study exists. The objective of this study was to assess the effectiveness and safety of etomidate as an induction agent for RSI in the pediatric ED. Methods: Data on RSI conditions and complications were collected prospectively on patients undergoing RSI in a tertiary pediatric ED from January 2003 to December 2003. ED hemodynamic data and inpatient data were collected retrospectively via chart review. Results: Seventy-seven of 101 patients requiring intubation underwent RSI with etomidate. The mean (+/- SD) age was 8.2 (+/- 6.2) years. All 77 patients were successfully intubated. Intubation condition data were available for 69 of 77 patients (89.6%). Conditions were good in 68 of 69 (99%; 95% confidence interval = 92.2% to 99.9%). The mean (+/- SD) maximal percent decrease in systolic blood pressure was 10% (+/- 13.6%). A greater than 20% maximal percent decrease in systolic blood pressure occurred in 12 of 69 patients (17.4%; 95% confidence interval = 9.3% to 28.4%). There was no relationship between seizures after etomidate administration and prior seizure history (p = 0.25). Corticosteroids were given to 29 of 77 patients post-RSI for varying diagnoses. All eight patients given corticosteroids for shock were in shock at the time of intubation. Conclusions: In the pediatric ED setting, etomidate as an induction agent provided successful RSI conditions and resulted in varied hemodynamic changes that were especially favorable in those patients presenting in decompensated shock. Hypotension and seizures were uncommon and occurred in patients with confounding diagnoses. Until the significance of a single dose of etomidate on adrenal dysfunction is further clarified, caution should be used in those patients at risk for adrenal insufficiency.