Etomidate can cause myoclonus, but the effect of this on intubation success rates has not been studied. Another study found no real significant difference between the two agents (82% for etomidate and 75% for midazolam. One study showed an equivalent success rate (83% for either agent alone, and 85% for the two used together). Studies, however, do not show an increased intubation success rate with etomidate compared to midazolam. It has a favorable hemodynamic profile it is not likely to cause hypotension, causing a more predictable sedative effect.

Įtomidate has a better profile as a possible induction agent for sedation-facilitated intubation.

Benzodiazepines also have a relatively slow onset and unpredictable efficacy in some patients. Various descriptions of sedation-facilitated intubation performed by prehospital agencies in the United States cite the use of drugs such as etomidate, midazolam, and ketamine as induction agents.īenzodiazepines such as midazolam can cause hypotension when used in dosages high enough to facilitate endotracheal intubation. Direct visualization in the mouth, along with external landmarks, is needed to assess the risk/benefit ratio of attempting to intubate with medication-facilitated intubation versus rapid sequence intubation or to simply continue with non-invasive methods of ventilation. If one is considering medication-facilitated intubation, the patient is already semi-comatose or in extremis and may not be able to follow directions. The basic anatomy evaluation is also limited due to the ability, or lack thereof, of the patient to participate. The presence of vomitus or foreign bodies in the airway and surgical alterations can make intubating very difficult, even with a normal Mallampati score. The Mallampati score alone does not offer complete coverage in ascertaining the ease of intubation. The likelihood of difficult intubation increases continuously from 0 (when no risk factor is present) to 2, 4, 8, and 17%, when one, two, three, and more than three factors are present. The patient should be evaluated for signs that intubation may be difficult: the presence of upper front teeth, history of difficult intubation, any Mallampati status different from 1 (2.55) or equal to 4, and mouth opening less than 4 cm. The utilization of medication-facilitated intubation compared to rapid sequence intubation also varies based on the patient's needs and the safety of the procedure. Regional and local use of medication-facilitated intubation and rapid sequence intubation is harder to ascertain, as there are no published studies regarding the extent of the use of drug-facilitated intubation other than on a statewide level. The remaining seventeen states (94.4%) with drug-facilitated intubation protocols use intubation with sedation and a neuromuscular blocking agent. Of those states, only one (5.6%) has a protocol for sedation-facilitated intubation. One recent study found that eighteen states (35.3%) have statewide drug-facilitated intubation protocols. Both procedures are performed to a varying degree by emergency medical service agencies across the nation.ĭrug-facilitated intubation protocols, including regulations for both medication-facilitated intubation and rapid sequence intubation, vary between states and, in many cases, between regional and local emergency medical service agencies. In comparison, rapid sequence intubation (RSI) employs both an induction agent and a paralytic drug. Facilitated intubation, also known as medication-facilitated intubation (MFI) or sedation-facilitated intubation, refers to intubation performed using a sedative or anesthetic drug as an induction agent, without the use of a paralytic (neuromuscular blocking agent).

Rapid sequence intubation process