A Retrospective Comparison of Etomidate and Ketamine for Prehospital Rapid Sequence Intubation

Etomidate and ketamine are commonly used to facilitate prehospital rapid sequence intubation. We aimed to estimate the association between sedative agents and outcomes in this patient population.

We evaluated all adult patients (≥18 years) in the ESO Data Collaborative research dataset during 2023 and 2024 who received ketamine or etomidate and a paralytic agent followed by an intubation attempt for inclusion. Our primary outcome was post-sedative cardiovascular collapse (systolic blood pressure [SBP] < 65 mmHg, vasopressor administration, or cardiac arrest), and secondary outcomes included intubation success and survival to hospital discharge. To compare sedatives, we used multilevel mixed-effects logistic regression with emergency medical services (EMS) agency as a random intercept adjusted for age, sex, pre-sedative airway suction, route (intravenous vs. intraosseous), patient type (trauma vs. medical), paralytic agent used, pre-sedative vital signs (minimum SBP, maximum heart rate, minimum peripheral oxygen saturation), pre-sedative minimum Glasgow coma scale, first-attempt video laryngoscopy use, first-attempt bougie use, and treatment year.

We analyzed 10,727 patients treated by 703 EMS agencies, of whom 5,505 (51.3%) received ketamine as a sedative before the first endotracheal intubation attempt. Etomidate administration was associated with decreased odds of cardiovascular collapse in comparison with ketamine administration (adjusted odds ratio [aOR], 0.56 [0.48-0.65]; n = 10,703). Sedative agent was not associated with the odds of first-attempt intubation success (aOR, 1.11 [0.97-1.27]; n = 10,703), overall intubation success (aOR, 1.19 [0.98-1.43]; n = 10,703), or mortality (aOR, 0.99 [0.80-1.21]; n = 3,074).

The use of etomidate as a sedative was associated with lower odds of hemodynamic instability after attempted rapid sequence intubation compared with ketamine.