The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation

The recent NEJM randomized controlled trial comparing ketamine and etomidate for rapid sequence intubation in critically ill patients reveals no statistically significant difference in 28-day mortality, with rates of 28.1% and 29.1% respectively. While ketamine is associated with a higher incidence of cardiovascular collapse, this finding is primarily driven by increased vasopressor requirements rather than cardiac arrest or profound hypotension. The open-label design introduces potential performance bias, complicating the interpretation of these secondary outcomes. Etomidate remains a robust first-line induction agent, particularly for patients with marginal hemodynamics, though ketamine retains value for specific clinical presentations like bronchospasm. Ultimately, the choice of induction agent is secondary to rigorous pre-intubation resuscitation, including the proactive management of hemodynamic stability and the immediate availability of vasopressors, which remain the most vital determinants of patient safety during the intubation process.