4. Swanson ER, Fosnocht DE, Neff RJ. The use of etomidate for rapid-sequence intubation in the air medical sestting. Prehosp Emerg Care. 2001;5:142–6. 5. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid-sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444–53. 6. Dunford JV, Davis DP, Ochs M, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003;42:721–8.
d In reply:–I thank Dr. Kim for his comments and agree with his contention that a properly performed rapid-sequence intubation (RSI) should include paralysis following appropriate sedation. I did not want to suggest that our study1 advocated an etomidate-only RSI protocol, but rather that a clinician with experience in intubation may elect to make an attempt at the
procedure following administration of etomidate, if proper conditions allow. Such conditions include a rapid single attempt at intubation with continuous monitoring of both pulse oximetry and cardiac rhythm, such as required by our program’s protocols. Under such conditions, we found that a reasonable number of patients did not require administration of the paralytic agent for intubation and that the procedure could be performed without significant complications. I am aware of the studies by Davis et al.2 and Dunford et al.3 and would argue that the skill of the clinicians in our air transport program as well as the oversight of their intubation procedures is significantly different from the skills of the study subjects in these authors’ settings. Each intubation performed is reviewed for number of attempts, complications, including episodes of hypoxia, and time to successful completion.
I hope that readers will not misinterpret our findings to support an etomidate-only RSI protocol; we continue to use succinylcholine as a routine part of our RSI procedure. HOWARD A. WERMAN MD Medical Director, MedFlight Columbus, OH
References 1. Werman HA, Schwegman D, Gerard JP. The effect of etomidate on airway management practices of an air medical transport service. Prehosp Emerg Care. 2004;8:185–90. 2. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid-sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444–53. 3. Dunford JV, Davis DP, Ochs M, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003;42:721–8.