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Point/Counterpoint | Etomidate Beats Ketamine for RSI

January 12, 2022

Essentials of Emergency Medicine Education Fellowship

The article summary for today is below, but first, a reminder. The last day to submit your entry is January 15, 2022. It’s coming up!

The EEM 2022 conference organizers are offering an amazing opportunity for EM residents anywhere in the U.S./Canada to serve as an EEM Fellow for the next EEM conference May 10-12, 2022.

JournalFeed and EEM have partnered to offer one mini-fellowship position to eligible residents anywhere in the U.S./Canada. Those selected to participate will receive:

  • FREE conference registration

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  • A travel stipend of US $500

JournalFeed’s contest involves writing a blog post about controversies in Emergency Medicine: present both sides of a clinical scenario, the best evidence and arguments for both, and summarize your take and recommendations in practice.

Click to learn more and apply!

Written by Nickolas Srica

Spoon Feed
The next couple of reviews will look at different authors making their case for why etomidate or ketamine should be the induction agent of choice for rapid sequence intubation (RSI) in the emergency department (ED).

Let’s start here with the case in favor of etomidate…

Etomidate rules, Ketamine drools
These authors made the following points for why they feel etomidate > ketamine for RSI in the ED:

  • Peri-intubation hypotension is associated with increased mortality, and since etomidate has a lower risk of hemodynamic deterioration, it should be the default induction agent.

  • Prior studies stating an association between etomidate and increased mortality in intubations for sepsis had findings that were confounded by differences in patient acuity.

  • Prior reviews found an association between bolus-dose etomidate (0.3 mg/kg) and decreased serum cortisol levels, but there is no known clinical or mortality impact that has been found for this association.

  • Prior studies in rats have shown significantly lower left ventricular contractility and relaxation when given ketamine versus etomidate, possibly suggesting myocardial depressant properties in ketamine that may precipitate hemodynamic compromise in critically ill patients with catecholamine depletion.

  • Two prior studies from the National Emergency Airway Registry (NEAR), though admittedly observational and susceptible to unmeasured confounding and possible indication bias per these authors, found post-procedure and peri-intubation hypotension more common in patients who received ketamine (no mortality difference found, more on this next time).

Michael D. April, Brit Long, Calvin A Brown 3rd. Deciding Whether to Use Etomidate or Ketamine as the Induction Agent of Choice for Rapid Sequence Intubation: Etomidate Should be the Default Agent for Rapid Sequence Intubation in the Emergency Department. Annals of Emergency Medicine. 2021. doi: 10.1016/j.annemergmed.2021.05.018

What are your thoughts?