Ketamine vs Etomidate in TBI – Prehospital Version

Written by Aaron Lacy

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Patients with TBI who were intubated in the prehospital setting had no difference in 30-day mortality when comparing induction with ketamine versus etomidate.

Are we still talking about ketamine vs etomidate in TBI?
This paper was a retrospective analysis of the Netherlands based BRAIN-PROTECT study, which looked at many aspects of prehospital management of patients with severe TBI. When looking at 30-day mortality of patients who were intubated with either etomidate or ketamine they found no significant difference between the two (32.9% v 33.8%; 95% CI 0.83-1.32, p=0.711). They looked at numerous secondary outcomes, but to me the most important was there was also no difference in Glasgow Outcome Scale (neurological outcome of discharged patients) between etomidate or ketamine (aOR 0.83; 95% CI 0.60-1.16, p=0.276). It should be noted all patients were intubated and transported by helicopter EMS teams, which may limit generalizability of procedural performance and subsequent patient outcomes.

How will this change my practice?
While I think the debunking of ketamine leading to increased intracranial pressure is far behind us, this study still holds value as systemic hemodynamics, especially hypotension, play a key role in cerebral perfusion. Additionally, prehospital induction may affect patients differently since it is happening near time of injury. This study reassures me that I can perform RSI in patients with suspected TBI with whichever induction agent I feel is best for the specific scenario.

Source
Etomidate versus Ketamine as prehospital induction agent in patients with suspected severe traumatic brain injury. Anesthesiology. 2024. Jan 8. Doi: 10.1097/ALN.0000000000004894. Online ahead of print.