Etomidate Preferred Over Ketamine for Emergency Intubation, Study Finds

Doctors treating seriously ill patients in an emergency setting may want too give the sedative etomidate, rather than ketamine, while placing a breathing tube, according to a randomized trial published in the New England Journal of Medicine.

The Randomized Trial of Sedative Choice for Intubation (RSI) is the first multicenter trial to demonstrate significant cardiovascular risks of high doses of ketamine (low blood pressure,arrhythmia),side effects that have not been well studied in the past.

We certainly know that patients receive treatments every day in hospitals around the world that have never been evaluated in a rigorous study and might potentially be ineffective or even harmful.

Jonathan Casey, MD, lead author, associate professor of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center

“Studies like RSI are critically important to understand the treatments that patients are already receiving and to ensure that patients receive the treatments that will result in the best outcomes,” he said.

Casey co-led the trial with Matthew Semler, MD, MSCI, associate professor of Medicine in the Division of Allergy, Pulmonary and Critical care Medicine at VUMC, along with a team of patients, clinicians and researchers from six cities across the U.S.

The RSI trial compared the use of ketamine and etomidate in 432 adults requiring emergency intubation. Researchers found that patients who received ketamine were more likely to experience serious cardiovascular events, including dangerously low blood pressure and irregular heartbeats.

Key Findings of the RSI Trial

• Ketamine was associated with a considerably higher incidence of cardiovascular events compared to etomidate.
• The risk of hypotension (low blood pressure) was notably higher in the ketamine group.
• Arrhythmias (irregular heartbeats) were also more common with ketamine use.
• The study provides strong evidence to reconsider the routine use of high-dose ketamine for emergency intubation.

The researchers emphasize that these findings have important implications for clinical practice. For years, ketamine has been favored by some clinicians due to its bronchodilating effects, which were thought to be beneficial in patients with reactive airway disease. However, this study challenges that assumption.

“We found no evidence that ketamine provided any benefit in patients with asthma or COPD,” said Semler. “In fact, we observed a trend toward worse outcomes in these patients.”

FAQ: Ketamine vs. Etomidate for Intubation

What is the main difference between ketamine and etomidate?

Ketamine is a dissociative anesthetic, while etomidate is a sedative-hypnotic. The study highlights that ketamine carries a greater risk of cardiovascular complications.

Is ketamine wholly contraindicated for intubation?

Not necessarily, but this study suggests clinicians should carefully weigh the risks and benefits, and consider etomidate as a preferred alternative, especially in patients with pre-existing cardiovascular conditions.

What about patients with asthma or COPD?

The study found no benefit and a potential trend toward worse outcomes with ketamine in patients with these conditions.

the research team plans to continue investigating optimal sedation strategies for emergency intubation, including exploring different doses and combinations of medications.

Publication Date: 2025/12/10 01:27:07