Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

Andrew H Merelman, Michael C Perlmutter, Reuben J Strayer
Western Journal of Emergency Medicine 2019, 20 (3): 466-471
Endotracheal intubation (ETI) is a high-risk procedure commonly performed in emergency medicine, critical care, and the prehospital setting. Traditional rapid sequence intubation (RSI), the simultaneous administration of an induction agent and muscle relaxant, is more likely to harm patients who do not allow appropriate preparation and preoxygenation, have concerning airway anatomy, or severe hypoxia, acidemia, or hypotension. Ketamine, a dissociative anesthetic, can be used to facilitate two alternatives to RSI to augment airway safety in these scenarios: delayed sequence intubation - the use of ketamine to allow airway preparation and preoxygenation in the agitated patient; and ketamine-only breathing intubation, in which ketamine is used without a paralytic to facilitate ETI as the patient continues to breathe spontaneously. Ketamine may also provide hemodynamic benefits during standard RSI and is a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine's unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety.

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Philip Cumpston

Endotracheal intubation is NOT a high risk procedure if carried out by people trained in its performance. But this takes practice. With the use of modern video laryngoscopes, it is even easier. Intubation using sedation without paralysis of the vocal cords has been shown to produce cord oedema and subsequent damage. This can be brought about by topical application of lignocaine or the use of muscle relaxants.
Using ketamine in the presence of raised intracranial pressure is absolutely contraindicated.
In Australia, emergency medicine doctors spend a minimum of six months rotating through anaesthesia in order to gain skills in airway management.
This paper demonstrates a poor response to inadequate training.
Philip Cumpston


Lorena Adams

Ketamine use in ICH??


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