Ketamine versus Etomidate for Rapid Sequence Intubation

Primary Recommendation

The Society of Critical Care Medicine suggests no difference between etomidate and other induction agents (including ketamine) with respect to mortality or the incidence of hypotension or vasopressor use in the peri-intubation period (conditional recommendation, moderate quality of evidence) 1
The American College of Critical Care Medicine explicitly recommends against etomidate in critically ill children, particularly those with septic shock 4

The Society of Critical Care Medicine guidelines indicate that etomidate provides the most reliable hemodynamic profile with minimal effect on blood pressure, making it suitable when hemodynamic stability is the primary concern 1
Etomidate is recommended when the patient has depleted catecholamine stores, as ketamine's sympathomimetic effects may paradoxically cause hypotension and cardiac arrest in such cases 1
The American College of Critical Care Medicine suggests considering ketamine for patients with septic shock, as avoiding etomidate-induced adrenal suppression is prudent in sepsis despite lack of proven clinical harm 1
Ketamine is beneficial when bronchodilation is necessary, such as in patients with chest trauma, aspiration risk, or reactive airway disease 3

Post-intubation hypotension occurs commonly with both agents and is associated with increased mortality, prolonged ICU stays, and organ dysfunction 1
The Society of Critical Care Medicine recommends having vasopressors immediately available during RSI with either agent 1
Ketamine has slightly higher rates of post-intubation hypotension compared to etomidate, although ketamine patients often had more difficult airways and higher baseline hypotension risk 6

The Society of Critical Care Medicine suggests administering the sedative-hypnotic agent before the neuromuscular blocking agent to prevent awareness during paralysis 6
Always follow sedation with neuromuscular blockade using succinylcholine 1-1.5 mg/kg or rocuronium 1.0-1.2 mg/kg 5

Ketamine maintains cardiovascular stability, which is critical in hemodynamically compromised seizure patients, making it a suitable choice for status epilepticus 5
Consider ketamine at reduced dosing (1 mg/kg) in geriatric patients with hypertension 6