Ketamine vs Etomidate for RSI

📧 EM Note Newsletter https://forms.gle/8boToiKDXVE3V8U19 Signup to get free weekly PDF via email. PS: Please join our membership for more perks (members can request for specific PDF file by posting in the EM Note YouTube Membership section). Homepage: EMNote.org ■ 🚩Membership: https://tinyurl.com/joinemnote 🚩ACLS Lecture: https://tinyurl.com/emnoteacls This lecture provides an evidence-based medicine (EBM) summary and critical appraisal of the RSI Trial, a large, multicenter Randomized Controlled Trial (RCT) that compared the use of ketamine versus etomidate as induction agents for emergency tracheal intubation in over 2,300 critically ill adults. The primary finding showed no significant difference in 28-day in-hospital mortality between the two groups, challenging the idea that etomidate's adrenal suppression leads to worse outcomes than ketamine. However, the trial revealed that ketamine was associated with a significantly higher rate of cardiovascular collapse during the procedure, including increased vasopressor use and hypotension, which suggests etomidate may be safer in terms of immediate hemodynamic stability. The study, although unblinded, is considered strong evidence and directly challenges clinical guidelines that often favor ketamine for hemodynamically unstable patients. --- Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults DOI: 10.1056/NEJMoa2511420 Background: For critically ill adults undergoing tracheal intubation, observational studies suggest that the use of etomidate to induce anesthesia may increase the risk of death. Whether the use of ketamine rather than etomidate decreases the risk of death is uncertain. Methods: In a randomized trial conducted in 14 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults who were undergoing tracheal intubation to receive ketamine or etomidate for the induction of anesthesia. The primary outcome was in-hospital death from any cause by day 28. The secondary outcome was cardiovascular collapse during intubation, defined by the occurrence of a systolic blood pressure below 65 mm Hg, receipt of a new or increased dose of vasopressors, or cardiac arrest. Results: A total of 2365 patients underwent randomization and were included in the trial population; 1176 were assigned to the ketamine group and 1189 to the etomidate group. In-hospital death by day 28 occurred in 330 of 1173 patients (28.1%) in the ketamine group and in 345 of 1186 patients (29.1%) in the etomidate group (risk difference adjusted for trial site, −0.8 percentage points; 95% confidence interval [CI], −4.5 to 2.9; P=0.65). Cardiovascular collapse during intubation occurred in 260 of 1176 patients (22.1%) in the ketamine group and in 202 of 1189 patients (17.0%) in the etomidate group (risk difference, 5.1 percentage points; 95% CI, 1.9 to 8.3). Prespecified safety outcomes were similar in the two groups. Conclusions: Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate. (Funded by the Patient-Centered Outcomes Research Institute and others; RSI ClinicalTrials.gov number, NCT05277896.)