The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial.

BACKGROUND: The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE: This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS: This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS: A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS: There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.

The Danger of Using Pop-Off Valves for Pediatric Emergency Airway Management.

BACKGROUND: Most pediatric resuscitator bags are equipped with a positive-pressure relief ("pop-off") valve meant to prevent delivery of excessive pressure. Pop-off valves, however, can lead to adverse events in emergency situations when providers are unaware of their significance. CASE REPORT: A 3-year-old girl with muscular atrophy and a chronic tracheostomy tube was noted to have decreasing oxygen saturations. Paramedics found the patient in cardiac arrest and initiated resuscitative efforts; the patient regained pulses but quickly became pulseless again. There were two more cycles of cardiac arrest followed by return of spontaneous circulation. When she arrived at the emergency department pulses were present. The emergency physician performed bag ventilation and felt no resistance to bag squeezing, but saw no chest rise, and realized the patient was not being ventilated because all of the air was escaping through the pop-off valve. When the valve was closed, it was impossible to perform bag ventilation. She was found to have complete occlusion of her tracheostomy tube; the paramedics had not been ventilating during transport, though were unaware of the occlusion because of the open pop-off valve. Removal of the tracheostomy tube and placement of an endotracheal tube significantly improved ventilation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pop-off valves are common on pediatric resuscitator bags, but often result in insufficient ventilation and oxygenation during emergency airway management. Emergency airway experts recommend that pop-off valves be avoided or deactivated during emergency resuscitation, but this information has not been widely disseminated.