Rapid Sequence Intubation (RSI): Ketamine For RSI

Mechanism of Action

Ketamine causes intense amnesia by inhibiting glutamine at the NMDA receptors in the thalamocortical and limbic central nervous system (CNS).

The heart rate, blood pressure, and cardiac output increase due to the sympathetic effects of ketamine through stimulating CNS outflow.
- This leads to fewer reuptake catecholamines from outside the cell which causes a rise in these chemicals within neurons as well as between them.

Dose

1 to 2 mg/kg (common, 100-200 mg)

Onset

Onset: ~ IV 30 seconds IM 3-4 minutes

Duration

Duration: 5-10 minutes

Adverse Effects

Hypertension
Tachycardia
Nausea & Vomitting
Emergence phenomenon

Ketamine Impact on Hemodynamics

Blood Pressure (BP)	Heart Rate (HR)	Cardiac Output (CO)	Intracranial Pressure (ICP)
↑ Increased	↑ Increased	↑ Increased	↔/ ↓ No Change/Decrease

Literature Review

Author, year	Design/ sample size	Intervention & Comparison	Outcome
Lyons, 2015	Cohort study/ n=261	Etomidate+ Succinylcholine (Group 1) vs Fentanyl+ ketamine+ rocuronium (Group 2)	Significantly better laryngeal views with fentanyl/ketamine/rocuronium group 100% first attempt intubation with fentanyl/ketamine/rocuronium group ↑ post-intubation MAP+ HR with etomidate + succinylcholine
Bruder, 2015	Cochrane Review	Etomidate Midazolam Propofol Ketamine	There was no difference in mortality, hospital LOS, duration of ventilation, and duration of vasopressors Etomidate associated with ↑ ACTH and ↓ in cortisol level
Jabre P, 2009	RCT/ n=469	Etomidate 0.3 mg/kg vs Ketamine 2 mg/kg	No difference in intubating condition, SOFA score, 28-day mortality, Ventilator free days, vasopressor support, or GCS

ACHT= Adrenocorticotropic hormone; GCS= Glasgow Coma; HR= Heart Rate; MAP= Mean Arterial Pressure; RCT= Randomized Controlled Trial; Scale; SOFA= Sequential Organ Failure Assessment;

Comments by ED Physician Attendings

Pro’s	Con’s
“Ketamine has some bronchodilatory properties and can be useful if intubating for asthma angioedema, airway narrowing from anaphylaxis, infection or malignant processes are the typical examples.”	“The dose should be greatly reduced in shock states- most notably hypovolemic shock as it is a direct myocardial depressant. There are some case reports of cardiac arrest when full induction doses of ketamine are pushed in these patients. In those patients, I will push 10mg at a time until dissociation occurs (usually around 0.2-0.3 mg/kg in my experience).”

Pros/Cons of Ketamine from ED Attendings

Comment

Ketamine has an analgesic effect unlike other induction agents

Ketamine has properties that treat seizures by decreasing excitation via inhibtion of NMDA receptor

Rapid Sequence Intubation (RSI) Masterclass

Introduction

Quizzes

Participants 396