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Hemodynamics in Helicopter Emergency Medical Services (HEMS) Patients Undergoing Rapid Sequence Intubation With Etomidate or Ketamine

  • Scott Kunkel
    Affiliations
    Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin

    Flight For Life, Waukesha, Wisconsin
    Search for articles by this author
  • Timothy Lenz
    Correspondence
    Reprint Address: Timothy Lenz, MD, Department of Emergency Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, HUB 3rd Floor, Milwaukee, WI 53226
    Affiliations
    Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin

    Flight For Life, Waukesha, Wisconsin
    Search for articles by this author

      Abstract

      Background

      Rapid sequence intubation (RSI) is performed by helicopter emergency medical services (HEMS) providers to establish airway control. Common induction agents are etomidate and ketamine, both touted to have relatively stable hemodynamic profiles. Limited data comparing these medications in the air medical setting exist.

      Objective

      Compare administration of ketamine and etomidate on peri-intubation hemodynamics.

      Methods

      A retrospective chart review of intubations performed by a HEMS program over 69 months was completed. Heart rate (HR) change, systolic blood pressure (SBP) change, and hypotension with etomidate or ketamine use were measured.

      Results

      There were 258 patients induced with etomidate and 48 with ketamine. Etomidate patients showed a +1.161% change in HR (SD ± 22.7) and −0.49% change in SBP (SD ± 25.0). Ketamine patients showed a −4.7% change in HR (SD ± 16.7) and 17.2% change in SBP (SD ± 43.4). The p-values for percentage change in HR and SBP between etomidate and ketamine were 0.0830 and 0.0018, respectively. Twenty-five episodes of postadministration hypotension occurred with etomidate, and two with ketamine (p = 0.028).

      Conclusion

      Both ketamine and etomidate are appropriate for intubation of HEMS patients. Ketamine was preferentially selected for hypotensive patients with statistically significant improvement in SBP. Although statistically significant, both ketamine and etomidate had relative low incidences of hypotension.

      Keywords

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      References

        • Upchurch CP
        • Grijalva CG
        • Russ S
        • et al.
        Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients.
        Ann Emerg Med. 2017; 69 (e2): 24-33
        • Bergen JM
        • Smith DC.
        A review of etomidate for rapid sequence intubation in the emergency department.
        J Emerg Med. 1997; 15: 221-230
        • Heffner AC
        • Swords DS
        • Nussbaum ML
        • Kline JA
        • Jones AE.
        Predictors of the complication of postintubation hypotension during emergency airway management.
        J Crit Care. 2012; 27: 587-593
        • Reynolds SF
        • Heffner J.
        Airway management of the critically ill patient: rapid-sequence intubation.
        Chest. 2005; 127: 1397-1412
      1. Nickson C. Rapid sequence intubation. 2015. Available at: https://litfl.com/rapid-sequence-intubation-rsi/. Accessed November 16, 2021.

        • Heffner AC
        • Swords D
        • Kline JA
        • Jones AE.
        The frequency and significance of postintubation hypotension during emergency airway management.
        J Crit Care. 2012; 27 (e9–13): 417
        • Lapinsky SE.
        Endotracheal intubation in the ICU.
        Crit Care. 2015; 19: 258
        • Simpson GD
        • Ross MJ
        • McKeown DW
        • Ray DC.
        Tracheal intubation in the critically ill: a multi-centre national study of practice and complications.
        Br J Anaesth. 2012; 108: 792-799
        • Nolan JP
        • Kelly FE.
        Airway challenges in critical care.
        Anaesthesia. 2011; 66 (suppl): 81-92
        • Deitch S
        • Davis DP
        • Schatteman J
        • Chan TC
        • Vilke GM.
        The use of etomidate for prehospital rapid-sequence intubation.
        Prehosp Emerg Care. 2003; 7: 380-383
        • Warner KJ
        • Cuschieri J
        • Jurkovich GJ
        • Bulger EM.
        Single-dose etomidate for rapid sequence intubation may impact outcome after severe injury.
        J Trauma. 2009; 67: 45-50
        • Cotton BA
        • Guillamondegui OD
        • Fleming SB
        • et al.
        Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients.
        Arch Surg. 2008; 143 (discussion 67): 62-67
        • Green SM
        • Roback MG
        • Kennedy RM
        • Krauss B.
        Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update.
        Ann Emerg Med. 2011; 57: 449-461
        • Scherzer D
        • Leder M
        • Tobias JD.
        Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients.
        J Pediatr Pharmacol Ther. 2012; 17: 142-149
        • Dewhirst E
        • Frazier WJ
        • Leder M
        • Fraser DD
        • Tobias JD.
        Cardiac arrest following ketamine administration for rapid sequence intubation.
        J Intensive Care Med. 2013; 28: 375-379
        • den Brinker M
        • Hokken-Koelega AC
        • Hazelzet JA
        • de Jong FH
        • Hop WC
        • Joosten KF.
        One single dose of etomidate negatively influences adrenocortical performance for at least 24h in children with meningococcal sepsis.
        Intensive Care Med. 2008; 34: 163-168
        • Jr Jackson WL
        Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: a critical appraisal.
        Chest. 2005; 127: 1031-1038
        • Sibley A
        • Mackenzie M
        • Bawden J
        • Anstett D
        • Villa-Roel C
        • Rowe BH.
        A prospective review of the use of ketamine to facilitate endotracheal intubation in the helicopter emergency medical services (HEMS) setting.
        Emerg Med J. 2011; 28: 521-525
        • Miller M
        • Kruit N
        • Heldreich C
        • et al.
        Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index.
        Ann Emerg Med. 2016; 68 (e2): 181-188
        • Morris C
        • Perris A
        • Klein J
        • Mahoney P.
        Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?.
        Anaesthesia. 2009; 64: 532-539
        • Jabre P
        • Combes X
        • Lapostolle F
        • et al.
        Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial.
        Lancet. 2009; 374: 293-300