Pharmacology of Etomidate For Rapid Sequence Intubation from the 2011 Pediatric Advanced Life Support (PALS) Manual

All that follows are direct quotes from the 2011 edition of the Pediatric Advanced Life Support Manual (1) except for text in brackets [comments] which is my commentary.

[Because advanced airway management is often necessary in pediatric patients with shock, rapid sequence intubation (RSI) is frequently necessary in the child who is not yet moribund. The question of whether and when to use etomidate or ketamine in pediatric RSI is very well reviewed in reference (2). And the PubMed Citations link in that reference allows review of other articles on this topic.]

Etomidate (p 215)

Classification: ultrashort acting on barbiturate, non-benzodiazepine sedative agent with no analgesic properties


  • Sedation for rapid sequence intubation (RSI)
  • Sedative of choice for patients with hypotension, cardiovascular disease, and multiple trauma. Agent of choice for intubation of patients with head injuries.

Available Forms: injection: 2 mg/mL

RSI 0.2 to 0.4 mg per kilogram IV/IO(maximum 20 mg) infused over 30 to 60 seconds produces rapid sedation that lasts 10 to 15 min.


  • Ultrashort acting non-barbiturate, non-benzodiazepine sedative hypnotic effect
  • No analgesic properties
  • Decreases intracranial pressure, cerebral blood flow, and cerebral basal metabolic rate


Absorption (Not applicable with IV/IO route of administration)
Excretion Hepatic and plasma esterases
Half-life 2.6 hours



  • Onset– 30 to 60 seconds
  • Peak– 1 min.
  • — Duration 10 to 15 min.

Monitoring: Monitor SpO2, respiratory function, and blood pressure frequently

Adverse Effects:

RESP Hypoventilation or hyperventilation
CV Hypotension or hypertension, tachycardia
GI Nausea, vomiting on emergence from anesthesia, myoclonic activity (coughing, hiccups)
ENDO Adrenal suppression
MISC Myoclonus, uncontrolled eye movements, pain at injection site


  • May suppress cortisol production after a single dose. Consider administration of stress those hydrocortisone (2 mg per kilogram; maximum dose 100 mg).
  • Avoid routine use in septic shock.
  • May also cause myoclonic activity (coughing, pickups) and may exacerbate focal seizure disorders.
  • Relative contraindications include known adrenal insufficiency or history of focal seizure disorder.
  • Contains propylene glycol.

Special Considerations:

  • Produces rapid sedation with minimal cardiovascular or respiratory depression
  • Because the drug may cause possible adrenal suppression, should not be used to maintain sedation after innovation. [See Ref (2) for information on post-intubation pediatric sedation]
  • Use of benzodiazepines or opioids may decrease myoclonus.


(1) Pediatric Advanced Life Support Manual, 2011, American Heart Association

(2) Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients [Full Text] [PubMed Citation]. Daniel Scherzer, MD et al. J Pediatr Pharmacol Ther. 2012 Apr-Jun; 17(2): 142–149.

(2) For a video on appropriate sedation of the pediatric patient please see  Sedating the Intubated Patient by Monica Kleinman, MD at Open Pediatrics. The site requires free registration.

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