You need tube, me give one amp of etomidate and SUX.

I t is axiomatic that resuscitation begins with airway stabilization. Recognition of the need to intubate may seem straightforward compared with the task of selecting which agent(s) to give, and at what dose, at a time when seconds count. Each sedative agent has its strengths and weaknesses, and a distinct dose–response curve. The choice of agents is made more difficult by the complexity of resuscitation hemodynamics and the disjointed and fragmented information available at the moment of intu-bation. It would be much less stressful if there were a simple algorithmic answer. Is etomidate that answer? In a Controversies piece appearing in this issue (see page 347), Zed and colleagues review some of the recent literature regarding one aspect of a long-standing controversy surrounding this medication. 1 Unfortunately, one is left with an even broader controversy: Do we need this drug at all? This question is particularly relevant in Canada, where etomidate is not approved for general use. It must be obtained by application to the Special Access Program , which is intended for non-approved drugs on a compassionate or emergency basis when conventional therapies have failed, are unsuitable, or are unavailable. In theory, a number of patient factors should influence selection of a sedative agent. However, local custom appears to be the most important. 2,3 Observations from the National Emergency Airway Registry confirm that in some US academic emergency departments, etomidate is used in over 80% of paralytic-assisted intubations. 2 Many emergency physicians believe that etomidate is the only agent to give with succinylcholine (SUX). Although the reasons given may vary, I suspect the most important reason is that, unlike thiopental, propofol or even midazolam, one can give the same dose to any adult and not expect the blood pressure to fall 3 minutes later. As a result, diagnostic uncertainties such as head injury with increased intracranial pressure, hemorrhagic shock, bronchospasm, systolic heart failure with acute ischemia, and cardiogenic shock are moot while the airway is being secured. It is also possible that historical barriers encouraged emergency physicians in some centres to select a drug that was no longer being used by anesthetists. These barriers are easy to forget in an era of procedural sedation by emergency physicians increasingly familiar with titrated propofol and ketamine. Yet is etomidate the best agent for all (except perhaps the septic patient), or is it merely the agent that requires the least consideration? Many …