Why is Etomidate not routinely used outside of hospital settings?

Etomidate is primarily not used outside of hospital settings due to its potential to cause adrenal suppression. This effect emerges because etomidate inhibits the enzyme responsible for cortisol production, which can lead to decreased cortisol levels. In a prehospital or out-of-hospital setting, the consequences of adrenal suppression could complicate patient management, especially in cases of trauma or severe infection where patients may already be under stress.

While etomidate is a potent sedative-hypnotic agent and is commonly favored for its favorable hemodynamic profile and minimal respiratory depression compared to other sedatives, these benefits are outweighed by the concern for adrenal suppression in non-hospital environments where immediate intervention and monitoring may not be available.

The other considerations, such as the risk of respiratory depression and the effectiveness for intubation, do not preclude its use outright, but adrenal suppression poses a significant risk that is particularly concerning in emergency situations. Availability is also not a limiting factor, as etomidate can be obtained by prehospital providers, but its clinical implications dictate its use primarily within hospitals.