Use of a protocol stipulating ketamine as the only induction agent reduced need for redosing and time to intubation.
Among the many induction agents available for rapid sequence intubation (RSI), ketamine is the least likely to cause hypotension. An academic Level 1 trauma center in California implemented an RSI protocol with ketamine (2 mg/kg) as the only induction agent. Investigators conducted a retrospective before-and-after study to determine the effects of the protocol.
The study included 266 trauma patients intubated during the year before implementation and 173 intubated during the 2 months after implementation. Induction agents used for RSI in the preimplementation group included etomidate, midazolam, and fentanyl. More patients required medication redosing to achieve RSI before implementation than after (6.4% vs. 1.7%). The time from medication administration to intubation decreased from 4 minutes before implementation to 3 minutes after. The authors did not report patient outcomes.
Reviewing Author
DisclosuresConsultant/Advisory BoardPortola Pharmaceuticals, Inc.
Speaker’s BureauPeerView Institute for Medical Education
Grant/Research SupportAgency for Healthcare Research and Quality; CDC; NIH–National Center for Advancing Translational Sciences; NIH–National Institute of Allergy and Infectious Diseases (NIAID); NIH–NIAID–Antibacterial Resistance Leadership Group; Merck; Pfizer; Boehringer-Ingelheim; Shire; Portola Pharmaceuticals, Inc.; Novartis; bioMérieux; Siemens; Rapid Pathogen Screening; Magnolia; Stago; Innovative Biosensors; Molecular Detection, Inc.; Dyax Corp.; Trius Pharmaceuticals
DisclosuresConsultant/Advisory BoardPortola Pharmaceuticals, Inc.
Speaker’s BureauPeerView Institute for Medical Education
Grant/Research SupportAgency for Healthcare Research and Quality; CDC; NIH–National Center for Advancing Translational Sciences; NIH–National Institute of Allergy and Infectious Diseases (NIAID); NIH–NIAID–Antibacterial Resistance Leadership Group; Merck; Pfizer; Boehringer-Ingelheim; Shire; Portola Pharmaceuticals, Inc.; Novartis; bioMérieux; Siemens; Rapid Pathogen Screening; Magnolia; Stago; Innovative Biosensors; Molecular Detection, Inc.; Dyax Corp.; Trius Pharmaceuticals
Citation(s):
Ballow SL et al. A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients. J Trauma Acute Care Surg 2012 Dec; 73:1401.
Comment
The authors correctly note that previous claims that ketamine increases intracranial pressure have been refuted by several studies. Ketamine's properties as an excellent analgesic and a dissociative anesthetic with minimal propensity to cause hypotension make it a good option for emergency department intubation.