A Comparison of Etomidate, Ketamine, and Methohexital in Emergency Department Rapid Sequence Intubation

Rapid sequence intubation (RSI) is routinely used for emergent airway management in the emergency department (ED). It involves the use of induction, and paralytic agents help facilitate endotracheal tube placement.

In response to a previous national drug shortage resulting in the use of alternative induction agents for RSI, we describe the effectiveness and safety of ED RSI with ketamine or methohexital compared with etomidate.

We conducted a retrospective, single-center observational study from March 1-August 31, 2012 describing RSI with etomidate, ketamine, and methohexital. All adult patients undergoing RSI in the ED who received etomidate prior to its shortage and methohexital or ketamine during the shortage were included.

The study included 47, 9, and 26 patients in the etomidate, ketamine, and methohexital groups, respectively. Successful intubation on the first attempt occurred in 74.5%, 55.6%, and 73.1% of the etomidate, ketamine, and methohexital groups, respectively. The mean number of intubation attempts and time to intubation seemed to be similar in all groups. At least three intubation attempts were required in 22.2% and 7.7% of the ketamine and methohexital groups, respectively, compared with none in the etomidate group. Two aspirations were observed in the etomidate group.

Methohexital and etomidate had similar rates of successful intubation on the first attempt and seem to be more effective than ketamine. Etomidate may reduce the need for three or more intubation attempts. Larger, prospective studies are needed to determine if ketamine or methohexital are more effective than etomidate for RSI.