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Abstract

Introduction: Rapid sequence intubation (RSI) is one of the most frequently performed procedures in emergency departments, but data describing the optimal sedative agent for induction during this procedure are limited. Hypothesis: The objective of this study was to compare the effectiveness of etomidate versus ketamine for RSI as measured by first-attempt intubation success. We hypothesized that ketamine is as effective as etomidate with regard to intubation success. Methods: This was a retrospective cohort study of prospectively collected data recorded in a quality improvement database between July 1st, 2007 and March 1st, 2012. The database contained information on all consecutive intubations performed in the emergency department during this time period. A multivariate logistic regression analysis was performed to determine the effect of sedative type on first-attempt intubation success. The model included other potential confounders such age, sex, trauma status, paralytic, difficult airway parameters, physician specialty, physician experience, reason for intubation and device used. Results: A total of 1511 RSIs were included in the final analyses. Of these, 1434 received etomidate and 77 received ketamine. The unadjusted rate of first-attempt intubation success was similar between the etomidate and ketamine groups (75% versus 83%, respectively; p=0.105;). In the multivariate analysis, variables predictive of first-attempt intubation success were sex (OR 0.70, 95% CI 0.99-1.00, p = 0.01), trauma status (OR 0.73, 95% CI 0.54-0.98, p = 0.04), intubation for cardiac arrest (OR 0.28, 95% CI 0.14-0.58, p<0.001), presence of at least one difficult airway parameter (OR 0.45, 95% CI 0.33-0.61, p<0.001), and use of GlideScope or C-Mac video laryngoscopes (OR 2.16, 95% CI 1.60-2.92, p < 0.001 and OR 2.23, 95% CI 1.51 to 3.28, respectively; p<0.001). After adjusting for potential confounders sedative type was not predictive of first-attempt intubation success (OR 0.72, 95% CI 0.38-1.36, p=0.305). Conclusions: Etomidate and ketamine produce equivalent rates of first-attempt intubation success in the emergency department.