Ketamine for Intubation in Atrial Fibrillation with Rapid Ventricular Response

Rationale for Ketamine Use

The American College of Cardiology recommends ketamine for intubation in patients with atrial fibrillation and rapid ventricular response, particularly if the patient is hemodynamically unstable, as it maintains hemodynamic stability better than most induction agents 1, 2

For hemodynamically unstable patients with atrial fibrillation and rapid ventricular response, the American College of Cardiology recommends immediate electrical cardioversion after securing the airway, and ketamine is the induction agent of choice because it preserves blood pressure and cardiac output 1, 2, 3
For hemodynamically stable patients with atrial fibrillation and rapid ventricular response, IV beta-blockers or nondihydropyridine calcium channel blockers are first-line for acute rate control, and ketamine remains a reasonable choice for intubation 1, 2, 3, 4

The American College of Cardiology recommends avoiding delay of intubation to achieve rate control first if the patient has a clear indication for emergent airway management, and instead addressing the rate control immediately after securing the airway 1, 3
The American College of Cardiology recommends considering pre-treatment with a beta-blocker immediately before induction if the patient is stable enough and time permits, to blunt the sympathetic response to laryngoscopy and the modest chronotropic effect of ketamine 3, 4

The American College of Cardiology recommends immediately addressing the rate control after securing the airway, with beta-blockers preferred in high adrenergic states, and continuous infusion of diltiazem may be needed after initial bolus 1, 3, 5
The American College of Cardiology recommends avoiding digoxin, diltiazem, or amiodarone if there is any concern for pre-excitation/WPW syndrome, as these can paradoxically accelerate ventricular response and cause ventricular fibrillation 1, 3, 4