Ketamine vs Etomidate for RSI in Trauma Patients

Hemodynamic Advantages of Ketamine

The Society of Critical Care Medicine recommends ketamine as a first-line induction agent alongside etomidate, with particular utility in hemodynamically unstable patients, due to its sympathomimetic properties that maintain hemodynamic stability 1, 2
Ketamine preserves blood pressure through endogenous catecholamine release, which is critical in hypovolemic or shocked trauma patients, although it can paradoxically cause hypotension in patients with depleted catecholamine stores 1, 3

Ketamine causes bronchodilation, which is particularly beneficial in trauma patients with chest injuries, aspiration risk, or underlying reactive airway disease 1

The Society of Critical Care Medicine notes that despite etomidate-induced adrenal insufficiency, no evidence demonstrates this causes negative clinical outcomes, and corticosteroid administration following etomidate is not recommended 2, 4

No significant difference exists in 30-day mortality between ketamine and etomidate in critically ill patients undergoing RSI, according to the 2023 Society of Critical Care Medicine guidelines 4

Administer ketamine at 1-2 mg/kg IV for RSI, using the lower end (1 mg/kg) in patients with cardiovascular compromise to minimize hemodynamic effects while maintaining adequate sedation 1, 2

The American College of Critical Care Medicine suggests that hemodynamically stable trauma patients can receive either ketamine or etomidate, while hypovolemic patients should receive ketamine, and septic trauma patients should receive ketamine over etomidate 1, 2, 4

Always have vasopressors immediately available during RSI with any induction agent, as post-intubation hypotension is common and associated with increased mortality, according to the Society of Critical Care Medicine 3
Ketamine is safe to use in head-injured patients when used with controlled mechanical ventilation, as historical concerns about increasing intracranial pressure have been refuted by evidence 1, 3

Peri-intubation hypotension rates in emergency department RSI were 18.3% with ketamine versus 12.4% with etomidate, according to recent registry data 3, 4

The Society of Critical Care Medicine recommends administering a sedative-hypnotic induction agent when a neuromuscular blocking agent is used for intubation, even in hemodynamically unstable patients, to prevent awareness during paralysis, which occurs in approximately 2.6% of emergency intubations 5

The 2023 Society of Critical Care Medicine guidelines suggest there is 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) 6, 5

Standard etomidate dosing is 0.2-0.3 mg/kg, with 0.15 mg/kg used in patients with hemodynamic compromise 6

Propofol has the most profound effect on blood pressure among induction agents and should be avoided in critically ill, hemodynamically unstable patients 6

Have vasopressors immediately available during RSI with any induction agent, as post-intubation hypotension is common and associated with increased mortality, prolonged ICU stays, and organ dysfunction 6
The Society of Critical Care Medicine suggests against administering corticosteroids following RSI with etomidate for the purpose of counteracting etomidate-induced adrenal suppression (conditional recommendation, low quality of evidence) 5