Etomidate or Ketamine Safe for Trauma Airway

Short Attention Span Summary

Ketamine or etomidate?
Vanderbilt switched from using etomidate for trauma RSI to ketamine because Trauma Surgery thought etomidate might be harming patients.  It causes adrenal suppression, no doubt, but the effects of that are probably nil.  This provided a before/after look to compare the two drugs.  Mortality was the same after the switch from etomidate to ketamine for induction, which means etomidate was safe after all.  It also means ketamine was as safe.  There were other secondary outcomes, some that favored ketamine and some that favored etomidate.  Given that a recent RCT showed no difference between the two agents, these minor differences are not conclusive in this non-randomized before/after study.

Spoon Feed
Etomidate and ketamine were equally safe when used as trauma airway induction agents.  Journal Watch did an excellent free summary of this article.


Abstract

Ann Emerg Med. 2017 Jan;69(1):24-33.e2. doi: 10.1016/j.annemergmed.2016.08.009.

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients.

Upchurch CP1, Grijalva CG2, Russ S3, Collins SP3, Semler MW4, Rice TW4, Liu D5, Ehrenfeld JM6, High K3, Barrett TW3, McNaughton CD3, Self WH7.

Author information:

1School of Medicine, Vanderbilt University Medical Center, Nashville, TN.

2Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN.

3Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.

4Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.

5Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.

6Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN.

7Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address: wesley.self@vanderbilt.edu.

Abstract

STUDY OBJECTIVE:

Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine.

METHODS:

The study entailed a retrospective evaluation of a 4-year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU-free days and ventilator-free days evaluated with multivariable ordered logistic regression using the same covariates.

RESULTS:

The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 0.92 to 2.16). Patients induced with ketamine had ICU-free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator-free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate.

CONCLUSION:

In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMCID: PMC5180365 [Available on 2018-01-01]

PMID: 27993308 [PubMed - in process]