RCT

RSI Ketamine-vs-Etomidate

Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults

NEJM, 2025 · Multicenter randomized trial (n=2365)

Clinical question

Does ketamine rather than etomidate improve survival for critically ill adults undergoing emergency tracheal intubation?

Population: Critically ill adults undergoing emergency tracheal intubation in emergency departments and ICUs
Intervention: Ketamine induction
Comparator: Etomidate induction
Primary outcome: In-hospital death by day 28
Result: Death by day 28 occurred in 28.1% with ketamine vs 29.1% with etomidate (P=0.65); cardiovascular collapse occurred in 22.1% vs 17.0%, respectively.

What the trial found

Ketamine did not improve survival compared with etomidate and was associated with more peri-intubation cardiovascular collapse in this trial.

Current guideline position

Contemporary randomized evidence informing physiologic RSI drug selection.

Clinical interpretation

Choose induction drugs according to patient physiology and contraindications; do not teach ketamine as universally hemodynamically safer than etomidate in critically ill adults.

Clinical Context & Relevant Topics (1)

Disease Reference

Airway Management & Rapid Sequence Intubation

The 7 Ps of ICU intubation, the physiologically difficult airway, BOUGIE/DEVICE video laryngoscopy trials, hemodynamic optimization, waveform capnography, and scalpel-bougie cricothyroidotomy.

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