Propofol on ER

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adgm

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Is anyone else watching this? So ridiculous for so many reasons.
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Is this a new thing? "Etomidate = conscious sedation"? I heard this in our ER last week too. They tried to replace a kid's bowels (poked through his ileocecal diversion) in the ED with etomidate and versed. Obviously, it didn't work and he came to the OR.

Bad, BAD idea, EM colleagues. Etomidate is far from a safe drug, for many reasons. And pushing it in the ED absolutely does not provide "conscious" sedation. Sadly, I think this is being done solely to get around FDA the labeling restrictions on propofol. Personally, I hate etomidate. I rarely use it. It's just not a good drug. If what is known about that drug now was known when they filed for FDA approval, it wouldn't be on the market. (Of course, same could be said for aspirin... if discovered now, it'd be about $8.00 a pill.)

-copro
 
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Apollyon said:
I did conscious sedation last weekend twice for ortho. I use ETOMIDATE. Less than 5 seconds, and out.

Propofol - eh, not my bag. (I'm watching, too - at least they mentioned the "milk of amnesia".)
Click to expand...

HAHAHAHAHAHAHAHAHA

:lol:

"YOU DA MAN, DUDE!"

BTW, are you open to some feedback on your "conscious sedation" technique?

If you are, great!

If not, I won't bother.
 
Uh, did anyone catch that the syringe of propofol that was used had just been used on the patient in the room next door?

Oh well - at least it was done by a "surgeon".
 
Apollyon said:
I did conscious sedation last weekend twice for ortho. I use etomidate. Less than 5 seconds, and out.

Propofol - eh, not my bag. (I'm watching, too - at least they mentioned the "milk of amnesia".)
Click to expand...

Less than 5 seconds? Yeah right.
 
jetproppilot said:
HAHAHAHAHAHAHAHAHA

:lol:

"YOU DA MAN, DUDE!"

BTW, are you open to some feedback on your "conscious sedation" technique?

If you are, great!

If not, I won't bother.
Click to expand...

OK, OK.

I'm changing my stance, since I know Apollyon is a stand up dude.

OK, Dude, you came in here without coverfire, defending your specialty against a flame from Plankton.

I respect that.

Now you've posted about a sedation technique that worked for you, and you've received some flames for it.

I'd like to step down from my throwing position here in the anesthesia forum, and welcome you here.

Thanks for stopping by. I know, since I've read alotta your stuff, that you're a stand-out dude at your profession.

Sorry about the sarcastic posts about your sedation technique.

I should've said,

"Dude, there are about a hundred different ways to accomplish sedation easily and effectively other than using etomidate."

I agree with JWK though.

Nobody awakens from anything in five seconds, unless you know something I don't.

But all that aside,

Welcome.

Having input from other specialists here is an asset.
 
I thought he was saying that the patient was "out" as in unconscious in less than 5 seconds. I didn't get the impression that he was saying the patient was awake in 5 seconds. Maybe I misread it.
 
I had never seen it go on so quickly - it surprised me.

I'm certainly, totally open to anything that can improve my practice.

I got really comfortable with etomidate when I was a resident. At Duke, where they ain't slouches in anesthesiology, they let us have it in the EM formulary.

What's scary is that the ortho residents usually do their own sedations.

One patient was a shoulder dislocation, and the other was a fibular fracture with a tibio-talar dislocation. Both went wonderfully. As to the onset, both the ortho resident and the nurses can attest to it. What I know is that it worked.

But give me all the bits - good and bad - about it, that anyone has ever had. I use it for sedation and induction for patients needing to be tubed.

edit: and the recovery wasn't 5 seconds, but as expected. The ankle lady was pretty big, and I dosed her at 0.15mg/kg, but had to redose with half the dosage.
 
I was watching ER and definitely remember reading about something similar in the news. Did a search and here is the article. If you you did not watch, a college student came b/c of an abscess or something, test were sent, results read over speaker phone, really bad news, guy is upset, surgeon grabs propofol and knocks the kid out (I dont remember all the details). Personally, I don't have a problem with the ethics behind using propofol the way it was used. I wouldn't want to hear that I am dieing, in a nonchalant tone from the doc over the phone. In the real life event, the anesthesiologist pushed the propofol.

http://www.time.com/time/health/article/0,8599,1671492,00.html
 
This is just my observations from volunteering in the ER. I have seen etomidate used a lot by the EM physicians. However, when they need to use propofol (e.g. reduce a fibula, tibia fx in a 10 yo) they call the peds anes. attending with resident to perform the sedation.
 
Technically, the doses mentioned and the fact the pt. is tolerating a reasonably painful procedure means that you've induced the patient not "sedated" them. Same as a good number of our "MAC" cases. As long as you can deal with the potential airway consequences, it works.
 
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jetproppilot said:
OK, OK.

I'm changing my stance, since I know Apollyon is a stand up dude.

OK, Dude, you came in here without coverfire, defending your specialty against a flame from Plankton.

I respect that.

Now you've posted about a sedation technique that worked for you, and you've received some flames for it.

I'd like to step down from my throwing position here in the anesthesia forum, and welcome you here.

Thanks for stopping by. I know, since I've read alotta your stuff, that you're a stand-out dude at your profession.

Sorry about the sarcastic posts about your sedation technique.

I should've said,

"Dude, there are about a hundred different ways to accomplish sedation easily and effectively other than using etomidate."

I agree with JWK though.

Nobody awakens from anything in five seconds, unless you know something I don't.

But all that aside,

Welcome.

Having input from other specialists here is an asset.
Click to expand...

I MUST humbly disagree.






a right cross


or


Matt Hughes choke hold.....


5 seconds ...tops...if you do it right.
 
Ok, I'm going to come to Apollyon's defense here...I work (as a paramedic/tech) in a private, community ED where etomidate +/- opioid is the standard of care for procedural sedation. Both new attendings and old farts use it. Reasons our physicians use it: predictable/reliable onset, no adverse hemodynamic effects (at least in our setting at our doses), short duration of action=quicker disposition, patients don't puke after emergence, and universally the patients are pleased.

Propofol is specifically forbidden from use for procedural sedation in both EDs I have worked in. In my experience benzo +/- opioid sedations are nowhere near as smooth as etomidate ones. And smoothness is what we are all interested in!

I'm sure your EM counterparts would like to hear some evidence about the safety and efficacy of various drugs that are currently accepted for use in the ED. Right now where I work, you either have etomidate or benzos at your disposal...so somebody has come to the conclusion that those are the best options for whatever reason.
 
canjosh said:
Ok, I'm going to come to Apollyon's defense here...I work (as a paramedic/tech) in a private, community ED where etomidate +/- opioid is the standard of care for procedural sedation. Both new attendings and old farts use it. Reasons our physicians use it: predictable/reliable onset, no adverse hemodynamic effects (at least in our setting at our doses), short duration of action=quicker disposition, patients don't puke after emergence, and universally the patients are pleased.

Propofol is specifically forbidden from use for procedural sedation in both EDs I have worked in. In my experience benzo +/- opioid sedations are nowhere near as smooth as etomidate ones. And smoothness is what we are all interested in!

I'm sure your EM counterparts would like to hear some evidence about the safety and efficacy of various drugs that are currently accepted for use in the ED. Right now where I work, you either have etomidate or benzos at your disposal...so somebody has come to the conclusion that those are the best options for whatever reason.
Click to expand...

Oh SNAP. (your neck) A paramedic is telling us the standard of care for anesthesia services provided by ED. That's as bad as a Physiatrist doing the same.
 
reasons not to use etomidate for sedation...

1. burns like hell going in - at least you can lido the prop a bit.
2. high incidence of myoclonus - see it all the time if not enough narcotic before pushing
3. severe nausea and vomiting
4. adrenal suppression, yes, even with one dose.
 
it was decided cause it was the CHEAPEST choice.

canjosh said:
Ok, I'm going to come to Apollyon's defense here...I work (as a paramedic/tech) in a private, community ED where etomidate +/- opioid is the standard of care for procedural sedation. Both new attendings and old farts use it. Reasons our physicians use it: predictable/reliable onset, no adverse hemodynamic effects (at least in our setting at our doses), short duration of action=quicker disposition, patients don't puke after emergence, and universally the patients are pleased.

Propofol is specifically forbidden from use for procedural sedation in both EDs I have worked in. In my experience benzo +/- opioid sedations are nowhere near as smooth as etomidate ones. And smoothness is what we are all interested in!

I'm sure your EM counterparts would like to hear some evidence about the safety and efficacy of various drugs that are currently accepted for use in the ED. Right now where I work, you either have etomidate or benzos at your disposal...so somebody has come to the conclusion that those are the best options for whatever reason.
Click to expand...
 
In all the shoulder dislocations I have personally had ( 6 in total) they have used Propofol for sedation in the ER.
In my anesthesia elective all I saw used was Propofol for induction. What are the negatives to this that would make Etomidate a better choice?
 
canjosh said:
[...] etomidate +/- opioid is the standard of care for procedural sedation [...] patients don't puke after emergence
Click to expand...

You've got this backwards. Etomidate is emetogenic, while propofol is an antiemetic.

canjosh said:
In my experience benzo +/- opioid sedations are nowhere near as smooth as etomidate ones. And smoothness is what we are all interested in!
Click to expand...

Etomidate is smooth because it's general anesthesia, not sedation. No kidding they don't move during the procedure.

What most of us are interested in is safety.
 
standard of care for specialists is not based on community standards but based on national standards...

etomidate sucks... the ED and ortho guys like it because they were exposed to it during their training...

having ED and Paramedics coming on this board to explain or discuss propofol/etomidate is like me going on the ED board and trying to discuss CVA algorithms... it is basically a waste of time --- just like the tv show ER has become a waste of time...
 
adgm said:
Is anyone else watching this? So ridiculous for so many reasons.
Click to expand...


I don't understand your post. Are you talking about an episode of the TV show ER? Did someone use propofol on the show? Or are you referring to a thread on the ER discussion board (I looked for one and didn't find one.)

If you are talking about the TV show, why the crap would you just assume most everyone else watches that horrible TV show? House, on the other hand, there's a show thats worth while.:)
 
epidural man said:
If you are talking about the TV show, why the crap would you just assume most everyone else watches that horrible TV show? House, on the other hand, there's a show thats worth while.:)
Click to expand...

Oh of course! House is sooooooooooooo realistic. :laugh:
 
The only realistic doctor show on TV is "Scrubs", in an intentionally caricaturish sorta way.

-copro
 
jwk said:
Oh of course! House is sooooooooooooo realistic. :laugh:
Click to expand...
You know what the sad thing is?
Kids watch these shows on TV and they actually think that this is what happens in reality: ER residents doing thoracotomies right and left on ER, an eccentric antisocial oxycontin user like Dr. House, not only practicing medicine but also surgery, dermatology, cardiology and sometimes psychiatry, and a group of residents who are playing God in some big town hospital but also have time for steamy romantic relationships and love triangles on Gray's anatomy.
I imagine many kids wanting to go into medicine just to be part of this fairy tale.
 
Tenesma said:
etomidate sucks... the ED and ortho guys like it because they were exposed to it during their training...
Click to expand...

See, this doesn't help me. I'm not "explaining" etomidate. Tell me why it sucks. It seems to be a global SDN Anesthesiology thing, but it's the first I've heard of it.

JPP offered some feedback, to which I'm completely amenable and for which I am still waiting.

And I have yet to meet anyone in gas that wants to come to the ED to perform procedural sedation.
 
myoclonus, adrenal suppression, nausea come to mind as side effects I'd rather avoid with etomidate. I rarely use it in or out of the OR for intubations or procedures. Its one of those things I need a reason to use rather than a reason not to. It is however, more forgiving to hemodynamics in the hands of those not experienced in titrating in other medications.
 
Apollyon said:
See, this doesn't help me. I'm not "explaining" etomidate. Tell me why it sucks. It seems to be a global SDN Anesthesiology thing, but it's the first I've heard of it.

JPP offered some feedback, to which I'm completely amenable and for which I am still waiting.

And I have yet to meet anyone in gas that wants to come to the ED to perform procedural sedation.
Click to expand...

Actually I've been sitting back and thinking outside the box on this one.

All the above posts list why I think etomidate is not a great drug.

It is falling out of favor in ORs across the US because of studies actually linking it to increased mortality.

We use propofol like most people use their county water system......

its in ubiquitous use, its predictable, its short acting, its antiemetic, blah blah blah.

I'm one of the few here thats a proponent of opening up its use for sedation.

I feel if an RN can learn to give fentanyl/midazolam cocktails for UGI/LGI cases, day in and day out, she can learn how to dose propofol.

Anyway,

I know why you guys are using it.

Its an induction/sedative agent that stuns someone, and you don't have to deal with the whole propofol-political thing.

We as an anesthesia community are using it less and less.

But if I were in your shoes, looking for an agent I can give devoid of alotta administrative bulls^it-drama,

what would I give?

I guess etomidate would be high on the list.

If it catches fire in the ED as the sedation drug of choice, only studies 5-10 years from now will tell us if all the things mentioned....lowering seizure threshhold/adrenal suppression/myalgias from myoclonus/pro-emesis properties...

have clandestinely, and more importantly, deleteriously effected your patient's outcomes.

I understand why you are using it in the short term.

But I think it is short sighted, and not a smart move for the long term.

BTW, I moonlighted like an animal in a busy ER when I was an anesthesia resident.

Three outta four weekends.

For three years.

I used midazolam many, many times for procedures....shoulder relocations, for example.

I'd administer it until they were totally buzzed out.....used it liberally...and mosta the time it worked.

Then I'd give flumazenil to wake them up, watchem for 90 minutes, and lettem go.

I know reversal is frowned upon because of residual effect, but because I was an anesthesia resident and knew most 80 year olds could take 5 mg and still breathe, I was very comfortable with it.

And if someone stopped breathing, well, airway was my gig, so I wasnt deterred. But I never had to intervene airway wise.....

What about that?

What about 2mg midaz and, oh, 20-50 mg ketamine?

Whats really sad is I'm suggesting things, working around the superior white elephant in the middle of the room (no white pun intended)....which is propofol....an agent I could teach my high school-cafeteria-working-mom to give judiciously in a cuppla weeks...

but I understand your position.

You'd like to use it, butcha cant.......right?

Thats my only synopsis that explains to me why you'd give etomidate over propofol.
 
Apollyon said:
See, this doesn't help me. I'm not "explaining" etomidate. Tell me why it sucks. It seems to be a global SDN Anesthesiology thing, but it's the first I've heard of it.

JPP offered some feedback, to which I'm completely amenable and for which I am still waiting.

And I have yet to meet anyone in gas that wants to come to the ED to perform procedural sedation.
Click to expand...
That brings up another question:
Do you think it is appropriate for an ER Doc to give an anesthetic to a patient so an Orthopod can reduce a fracture?
I have seen it done and I thought this should be beyond the scope of practice of ER Medicine.
 
lobelsteve said:
Oh SNAP. (your neck) A paramedic is telling us the standard of care for anesthesia services provided by ED. That's as bad as a Physiatrist doing the same.
Click to expand...

I told you that it is the standard in the small, community ED in which I work...and it is. You can argue with me all you want, but I do work in the ED in which I am telling you about, and I take part in procedural sedation during nearly every shift. I'm not telling anybody on these boards how to practice any field of medicine, I'm telling you how I see it practiced by others. How being a paramedic somehow disqualifies me from sharing MY experience regarding the standard of care in MY workplace is perplexing, but I digress. I was looking for what JPP ultimately provided, evidence for people like Apollyon to use in their practice of Emergency Medicine. .
 
swpm said:
You've got this backwards. Etomidate is emetogenic, while propofol is an antiemetic.



Etomidate is smooth because it's general anesthesia, not sedation. No kidding they don't move during the procedure.

What most of us are interested in is safety.
Click to expand...

I was making an anecdotal comparison between etomidate and benzo sedations...not etomidate vs propofol...if that's what you were thinking. From the ED perspective, it is frustrating to hear "XYZ drug sucks, the ED guys are *****s for using it." Anesthesia says propofol is great, but only anesthesia can administer it. Ya'll don't generally provide services in the ED...so where does that leave the EDP? Stuck using what is available/allowed, while being told that the available/allowed drugs are unsafe/ineffective/inappropriate, etc.

It should go without saying that unsafe=unsmooth, I suppose I could have chosen a different word in the original post.
 
Deep sedation or GA in the ER still leaves an airway unprotected. I have seen a few aspirations from ER failures.
A little anesthesia knowledge can be a dangerous thing.
Most 16y.o drivers think their the best!!!!
 
canjosh said:
Ya'll don't generally provide services in the ED...so where does that leave the EDP? Stuck using what is available/allowed, while being told that the available/allowed drugs are unsafe/ineffective/inappropriate, etc.
Click to expand...

Sedation in the ER (or anywhere) is a touchy subject, because it's easy to go too far and wind up with a general anesthetic - typically with an unsecured airway in a trauma patient with a full stomach. Most would agree that this is not a good thing.

The ER docs at your institution are licensed physicians, and sedation is within their scope of practice. If another department (anesthesiology) is dictating what drugs stocked are in their realm, they need to put on their big boy pants and fight that pharmacy political battle. Not just cue the Bon Jovi cowboy music, and charge ahead with off-label use of an inferior drug.

What will they do when the all-powerful anesthesiologists realize that they're using etomidate for "sedation" in the ER, and get that drug banned too? Uncork the whiskey bottle?

I know you're just reporting what you've observed, and that the sedation techniques at your hospital aren't yours to choose. Not really trying to pounce on you personally.
 
Planktonmd said:
That brings up another question:
Do you think it is appropriate for an ER Doc to give an anesthetic to a patient so an Orthopod can reduce a fracture?
I have seen it done and I thought this should be beyond the scope of practice of ER Medicine.
Click to expand...

One doctor is doing the procedure, and the other is doing the sedation. Maybe it's the "law and order" persona in me, but I always have taken it very seriously - I don't "look over the drape".

In that it's not one person trying to juggle both, I certainly think it is appropriate.
 
So, big props go out to Jet - did it today for the first time! Propofol sedation!

I thought she had enough analgesia on board, but, right in the middle of the procedure (putting on a posterior splint on a woman with multiple fractures, whom the orthopod said had "ghost bones" on the radiographs), she opens her eyes and goes, "Ow, ow, OW!" Husband stays calm.

Finish the splint, and, maybe 3 minutes later, she comes back up and I asked her if she remembers anything, and she says "no, nothing".

Milk of Amnesia, indeed!

Now, mind you, me doing the sedation and procedure directly contradicts what I stated in the post above me, but you have to do what you have to do, you know?
 
Apollyon said:
So, big props go out to Jet - did it today for the first time! Propofol sedation!

I thought she had enough analgesia on board, but, right in the middle of the procedure (putting on a posterior splint on a woman with multiple fractures, whom the orthopod said had "ghost bones" on the radiographs), she opens her eyes and goes, "Ow, ow, OW!" Husband stays calm.

Finish the splint, and, maybe 3 minutes later, she comes back up and I asked her if she remembers anything, and she says "no, nothing".

Milk of Amnesia, indeed!

Now, mind you, me doing the sedation and procedure directly contradicts what I stated in the post above me, but you have to do what you have to do, you know?
Click to expand...

WOW!

Nice job, Dude.

Theres a learning curve with it like anything else.

You'll have it figured out in no time. :thumbup:
 
Apollyon said:
So, big props go out to Jet - did it today for the first time! Propofol sedation!

I thought she had enough ANALGESIA on board, but, right in the middle of the procedure (putting on a posterior splint on a woman with multiple fractures, whom the orthopod said had "ghost bones" on the radiographs), she opens her eyes and goes, "Ow, ow, OW!" Husband stays calm.

Finish the splint, and, maybe 3 minutes later, she comes back up and I asked her if she remembers anything, and she says "no, nothing".

Milk of Amnesia, indeed!

Now, mind you, me doing the sedation and procedure directly contradicts what I stated in the post above me, but you have to do what you have to do, you know?
Click to expand...

Just wanna point out that propofol isnt an analgetic, so cant provide analgesia....

......propofol, etomidate, thiopental et al are induction agents....or more correctly, sedative hypnotics.

So after you give your "hypnotic", your sentence would look like...

"I thought she had enough hypnotic on board"...

An analgetic provides analgesia....analgetics are morphine, meperidine, fentanyl, (opiods....you get the point)....and I guess NSAIDS, Cox-2s etc could be considered analgetics.....anyway....anything that provides pain relief....something propofol/etomidate/thiopental et al can't do.

Not being critical....just edumacating you so you can look even cooler in the ED. :laugh:
 
That's what I meant (again, can't express myself worth a damn...) - I did not know until today (as I was making sure I didn't do the wrong thing) that propofol does not have analgesic properties - I meant that I thought I'd already hit her with enough opiate to cover her.

And, you're totally right (as usual) - learning curve, but not too steep (I mean, if I can do it...).
 
Apollyon said:
So, big props go out to Jet - did it today for the first time! Propofol sedation!

I thought she had enough analgesia on board, but, right in the middle of the procedure (putting on a posterior splint on a woman with multiple fractures, whom the orthopod said had "ghost bones" on the radiographs), she opens her eyes and goes, "Ow, ow, OW!" Husband stays calm.

Finish the splint, and, maybe 3 minutes later, she comes back up and I asked her if she remembers anything, and she says "no, nothing".

Milk of Amnesia, indeed!

Now, mind you, me doing the sedation and procedure directly contradicts what I stated in the post above me, but you have to do what you have to do, you know?
Click to expand...



Just curious, how did you dose the propofol, and did you give anything else with it?
 
Apollyon said:
That's what I meant (again, can't express myself worth a damn...) - I did not know until today (as I was making sure I didn't do the wrong thing) that propofol does not have analgesic properties - I meant that I thought I'd already hit her with enough opiate to cover her.

And, you're totally right (as usual) - learning curve, but not too steep (I mean, if I can do it...).
Click to expand...

How much did you give?

Just curious...

...not that theres some right dose to start with, but I'll give you some proprietary information. :)laugh:)

You can give my seventy-four-year old mom fifty milligrams of 2-6-diisopropyl phenol right now. Squirt it in her IV. Walk away. And she'll be OK.

Thats where I usually start if its an old person. You can always squirt in more.

For somebody like Mil, :)laugh:), say for a closed reduction of a radius after he leaned into a corner a little too tight trying in vain to beat a Hayabusa, :)lol:), I'd probably start with 100mg. You'll probably need more on a young person, but thats a good start.

So ya dose based on a guess of how the patient will respond.

Over-did it a little? Patients apneic?

No need to fret.

This is perfect for the start of the procedure. Don't intervene. Don't dial 911. Don't call a CODE. Don't yell "WE'RE LOSIN' HER!!!" like on ER.

 Tell ortho dude to go ahead.... an increase in stimulation (OK, dudes feeling PAIN) will make'em breathe again.

Point being, if you ever give a sedation agent to the point of apnea, change the level of stimulation to make them breathe again. Start the procedure. Givvem' an assertive jaw lift. Pinch their earlobe between the fingernails of your birdie finger and your thumb.

Most of the time this change of stimulation makes 'em breathe.

If not, well, you're a board certified dude and know how to handle it....which isnt any big deal, either.

But it almost never gets to this point.

If it does, you intervene for a few minutes, then alls golden again.
 
Apollyon said:
One doctor is doing the procedure, and the other is doing the sedation. Maybe it's the "law and order" persona in me, but I always have taken it very seriously - I don't "look over the drape".

In that it's not one person trying to juggle both, I certainly think it is appropriate.
Click to expand...
So should we consider ER physicians anesthesia providers?
 
Planktonmd said:
So should we consider ER physicians anesthesia providers?
Click to expand...

CUMM'ON, PLANK.

GIMME A *****NG BREAK, DUDE.

Ya think any anesthesia department on the planet has the desire/ability to run down to the ER every time an ER physician or a consultant in the ER needs sedation?

In my bum-fuk-egypt gig, every once in a while we'd go to the ER and squirt some propofol into a dislocated hip patient's IV for an orthopedist that was one of our premium playas.

That was preferential treatment for a dude that made us, literally, millions of dollars.

But thats not sustainable....we couldnt always go...

At my current gig theres no way we could provide that type of service.

How do you staff for something like that? The ER, where anything could happen at anytime?

You can't.

Far better to get the ER docs comfortable with sedation.

They're doctors.

Actually they're, behind us, the best at airway management.

So wheres your beef with this?
 
and hopefully it doesnt need to be said, but...HAVE THEM ON OXYGEN. It'll at least buy you a little more margin for the apnea.
 
Had her on O2, she's an ASA 3, and a Mallampati 3. She's about 56 kilos, and stuff I read said cut it down to 80%, so I was going to give her 45mg (over 2-3 minutes, per the lit, and not to bolus it in the ASA 3's or higher), but, since I had to give it, I actually gave her 50mg. Worked like a charm.

I did not give anything else at the time. Maybe should have. Still, it worked out really well. I even explained to the patient and husband what I was thinking, between Versed, etomidate, and propofol. I said that etomidate wasn't a good choice, because it is emetogenic ("that means it makes you throw up") and the myoclonus - and she agreed with me that she didn't want her foot bobbing up and down.

When I was a resident rotating in the MICU at Duke (by the way, Duke IM sucks at acute critical care, and seem afraid of procedures - or they did - but they kick *** at pulmonary), they would intubate with a "stick" of propofol - 40mg bolused, take it or leave it - that's all you got. My n=1 of seeing this worked, but I didn't think (because I didn't know) to ask what they would do if it wasn't enough.
 
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