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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: The use of etomidate as a sedative was associated with lower odds of hemodynamic instability after attempted rapid sequence intubation compared with ketamine.