Pediatric emergency medicine trisk 0174 0174
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Ketamine is a dissociative anesthetic with reliable and rapid onset. It has the
beneficial effects of augmenting hemodynamics, making it the theoretical drug of
choice for patients who are at risk for cardiovascular depression. Ketamine is
commonly used as a procedural sedative/analgesic since it preserves airway
reflexes and respiratory drive, but its adverse effects include vomiting,
laryngospasm, and emergence delirium. In the context of RSI, these adverse
effects have less significance. Ketamine increases oral secretions (a sialogogue).
The coadministration of atropine is often recommended to counter this, however
the onset of this effect takes 15 to 20 minutes and therefore is unlikely to impact
laryngoscopy and intubation. Ketamine maintains cardiovascular responses by
blocking reuptake of catecholamines. Earlier studies have suggested that
ketamine increases ICP. This led to the widespread belief that ketamine is
relatively contraindicated in head trauma, which is a frequent indication for RSI.
Newer studies and analyses suggest that ketamine’s effect on ICP is variable and
that it benefits cerebral perfusion pressure and systemic arterial pressure.
Ketamine is reported to have bronchodilator properties which favors its selection
in status asthmaticus; however, data are limited.
Etomidate provides reliable rapid-onset sedation, reliable pharmacokinetics,
and cardiovascular stability. It has no effect in ICP. While some sources have
described etomidate as having cerebroprotective properties, the primary source of
proof for this is difficult to find. Some nonrandomized trials have demonstrated
poorer outcomes in patients receiving etomidate. This applies to both single-use
etomidate for ED RSI and for longer-term use of etomidate in the ICU. Etomidate
use was associated with greater hypotension in septic patients, a higher rate of
ARDS and multiple organ dysfunction in severely injured trauma patients, trends
toward longer ventilator courses and hospital stays, and an increase in mortality.
These outcomes are commonly attributed to the known suppression of adrenal
function following administration of etomidate. However, more recent
randomized trials and meta-analyses, primarily using data from adults, have not
shown difference in mortality or hospital utilization when using etomidate.
Nonetheless, PALS and other guidelines consistently raise caution on its use in
patients with septic shock.
Propofol is a commonly used sedative in general, yet its role in ED RSI is
unclear. Propofol is a potent vasodilator and myocardial depressant, resulting in a
significant risk of hypotension which makes it unsuitable for hypovolemic
patients, children in shock, or patients in whom the maintenance of cerebral
perfusion is essential. While some sources have described propofol as having
