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Point/Counterpoint | Ketamine Beats Etomidate for RSI

January 13, 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

  • FREE 4-night hotel stay at the Hilton Union Square, San Francisco, CA

  • 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
Here are the main points for why these authors feel ketamine should be the preferred induction agent over etomidate for emergency department (ED) rapid sequence intubation (RSI).

Ketamine goes to college to get more knowledge; Etomidate goes to Jupiter to get more stupider
These authors had these key points to make for why they think ketamine > etomidate for RSI in the ED:

  • Ketamine is an indirect, weak sympathomimetic agent that can lead to improved hemodynamic effects by limiting reuptake of catecholamines, making it a preferred agent in hypotensive patients.

  • The two recent large observational studies from the National Emergency Airway Registry (NEAR) reported higher rates of post-procedure hypotension in patients given ketamine compared to etomidate, but these studies had significant limitations including: a retrospective design at risk of confounding, potential indication bias, no control over the time clinicians were given to complete the data (possible recall bias), and the patients in the ketamine group being more likely to have difficult intubation risk factors and disease states, to list a few. Larger randomized controlled trials would be needed to draw these conclusions more accurately.

  • The 2009 KETASED study was a randomized controlled trial evaluating etomidate versus ketamine for RSI in acutely ill patients, and this study established ketamine as a viable alternative without the above findings.

  • Ketamine can cause bronchodilation in patients with asthma.

  • Ketamine has both sedative and analgesic properties, while etomidate has only sedative properties.

  • Ketamine does not lead to adrenal suppression, whereas the 2009 KETASED study found etomidate increased the odds of adrenal insufficiency 6.7-fold compared with ketamine (with the clinical significance of this still leading to some debate).

    • This, and some other data, has led to the Surviving Sepsis Guidelines to provide a weak recommendation against etomidate in pediatric sepsis patients, and a recommendation for cautious use in adult sepsis patients.

  • Earlier concerns about ketamine increasing intracranial pressure in traumatic brain injury patients have more recently been found to be unjustified compared to other induction agents.

My institution definitely tends to lean more heavily toward the ketamine side here, but at the end of the day the choice will ultimately be yours to make, so choose wisely… dun dun duuun.

Gary D. Peksa, Michael Gottlieb. Deciding Whether to Use Etomidate or Ketamine as the Induction Agent of Choice for Rapid Sequence Intubation: Ketamine Should be the Preferred Agent for Rapid Sequence Intubation. Annals of Emergency Medicine. 2021. doi: 10.1016/j.annemergmed.2021.07.118

What are your thoughts?