Podcast
REBEL EM – Emergency Medicine Blog
Hosted by Salim R. Rezaie, MD · EN
Rational Evidence-Based Evaluation of Literature
23episodes
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Clinical Conundrums: Should Ketamine be Preferred Over Etomidate in RSI?
Sep 23, 2024Tap to summarizeBottom Line Up Top: Based on the available evidence, we should strongly consider ketamine over etomidate as our default induction agent in critically ill patients. Clinical Scenario: A 48 year old man presents with fever, hypotension, hypoperfusion and hypoxemia. Workup reveals multifocal pneumonia and oxygenation only marginally improves with non-invasive ventilation. You decide to intubate the patient after resuscitation. You are handed a vial of etomidate but consider whether you should use ketamine instead. What Your Gut Says: It probably doesn’t make any difference. Just give whichever agent you’ve got. What The Evidence Says: Etomidate has long been the favored induction agent for ED RSI in the US. The drug has a number of reported advantages including rapid onset and a favorable hemodynamic profile (etomidate itself does not cause vasodilation or cardiac depression). However, it is well-established that even a single dose of etomidate can cause adrenal suppression (Albert 2011). Proponents of its use often dismissed this effect of the drug as there had never been any evidence it impacted clinical outcomes. Additionally, better alternative induction agents were not available (midazolam and propofol both have intrinsic hemodynamic properties making them less than ideal). More recently, ketamine has offered an alternative approach to induction. Much like etomidate, it doesn’t have intrinsic hemodynamic effects. Ketamine can lead to increases in blood pressure due to release of endogenous catecholamines. This effect is unlikely to be significant in those with severe or critical injury as they are likely to be catecholamine depleted. Unlike etomidate, ketamine offers the advantage of having no effect on the adrenal glands. Opponents of ketamine often point to the risks of spiking intracranial pressure but this concern has been widely debunked (Cohen 2015). In the past, the literature has offered inconsistent conclusions on which drug is preferred. However, two recent publications have started to shift the scales towards ketamine. In 2023, a meta-analysis of randomized trials demonstrated a 3% increased mortality associated with etomidate giving a number needed to harm of 31 (for every 31 patients given etomidate for RSI, there will be one additional death) (Kotani 2023). In 2024, a Bayesian meta-analysis was performed looking at randomized controlled trials comparing ketamine to etomidate in critically ill patients. This study reported that there was “moderate probability that induction with ketamine is associated with a reduced risk of mortality,” (Koroki 2024). The available evidence isn’t completely convincing and it would be disingenuous to completely remove etomidate as an induction agent based on these findings, however, there does appear to be consistency of the findings favoring ketamine over etomidate with no recent data favoring etomidate over ketamine. Bottom Line: Based on the available data, it would be reasonable to favor ketamine over etomidate as an induction agent in critically ill patients. However, the evidence isn’t adequate to call for a wholesale change and etomidate should not be discarded as a useful alternative agent. Read More REBEL EM: From Debate to Data: Emerging Insights into Induction with Ketamine vs Etomidate. References Albert SG, Ariyan S, Rather A. The effect of etomidate on adrenal function in critical illness: a systematic review. Intensive Care Med. 2011;37(6):901-910. PMID: 21373823 Cohen L et al. The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic Review. Ann Emerg Med 2015; 65(1): 43-51. PMID: 25064742 Kotani Y et al.Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials. J Crit Care 2023;77:. PMID: 37127020 Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):PMID: 38368326 The post Clinical Conundrums: Should Ketamine be Preferred Over Etomidate in RSI? appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →REBEL Core Cast 127.0 – Penetrating Neck Injuries
Sep 18, 202400:09:06Tap to summarizeTake Home Points Anticipate anatomically challenging airways and consider early intubation prior to loss of airway anatomy. Skip the zones of the neck and focus on hard signs of vascular (Shock w/o another source, Pulsatile bleeding, Expanding hematoma, Audible bruit, Signs of stroke) or aerodigestive (Airway compromise, Bubbling wound, Extensive SubQ air, Stridor, Significant hemoptysis/hematemesis). The presence of hard signs indicates the need to go to the OR or for angiographic intervention. Control hemorrhage with a single finger and direct pressure. REBEL Core Cast 127.0 – Penetrating Neck Injuries Click here for Direct Download of the Podcast. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 127.0 – Penetrating Neck Injuries appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →The Ducanto Catheter—It Sucks!
Sep 2, 2024Tap to summarizeBackground: Emergency intubations present a unique set of challenges, particularly when dealing with heavily contaminated airways. Anesthesiologist, Dr. James DuCanto, developed the DuCanto catheter to enhance airway management in these high-stakes situations. The commonly used 14 Fr Yankauer catheter, with its smaller bore, may struggle to clear heavily contaminated airways effectively. In contrast, the 28 Fr DuCanto catheter is specifically designed to handle thicker fluids which may be seen in emergency airway management, potentially making it the better choice for the ED.1 The head-to-head performance of these devices has not been previously studied. Paper: Finke SR, Schroeder DC, Ecker H, Böttiger BW, Herff H, Wetsch WA. Comparing suction rates of novel DuCanto catheter against Yankauer and standard suction catheter using liquids of different viscosity-a technical simulation. BMC Anesthesiol. 2022;22(1):285. Published 2022 Sep 10. PMID: 36088303 Research Question: How effective is the DuCanto catheter, compared to the Yankauer and standard suction catheters, at suctioning liquids of different viscosities? What They Did: Investigators conducted a technical simulation in a laboratory setting. They compared the suction rates of 3 different catheters across 4 different fluid viscosities. Each catheter was used to suction the four different fluids for 15 seconds. The procedure was repeated four times for each catheter and fluid combination to ensure the reliability of the measurements. Data were analyzed using one-way ANOVA and the Holm-Sidak method to determine statistically significant differences between the catheters. Comparators: DuCanto catheter (28 Fr, large-bore) Yankauer catheter (18 Fr, large-bore) Standard suction catheter (14 Fr) Primary Outcome: Suction Rate: The amount of liquid removed by suctioning (in milligrams) during a 15-second timeframe using each of the catheters across four different fluids with standardized viscosities. Results: Strengths: Controlled Environment: The study was conducted in a controlled laboratory setting, which allowed for precise measurements of suction rates and consistent conditions across all experiments. Standardized Viscosity Levels: The use of standardized fluids with controlled viscosities (water, syrup-like, honey-like, pudding-like) provided a reproducible method to compare the performance of different suction catheters. Direct Comparison: The study directly compared three commonly used suction catheters (DuCanto, Yankauer, and standard catheter) under identical conditions, making the results relevant and easily interpretable. Objective Measurements: Suction performance was measured quantitatively in milligrams, providing clear, objective data on the effectiveness of each catheter. Multiple Trials: Each suctioning procedure was repeated four times for each catheter and viscosity level, enhancing the reliability of the results. Limitations: Bench Model Simulation: The study was conducted in a laboratory setting rather than a clinical environment, which may only partially replicate the complexities and variability of real-life clinical situations. Lack of Corpuscular Elements: The study did not include solid or semi-solid particles (e.g., food particles, coagulated blood clots), which are often present in real-world scenarios and could affect suction performance. No Clinical Trials: The study did not involve human or animal subjects, so the findings are limited to technical performance and do not provide direct evidence of clinical efficacy or safety. Non-blinded Design: The study staff could not be blinded to the type of catheter being used, which could introduce bias, although the objective nature of the measurements likely minimized this risk. Device-Oriented Outcomes: While suction rate improvements were significant, the clinical relevance of these findings remains uncertain. Single Suction Unit Setting: The study used a single suction pressure setting (-600 mbar) for all tests, which may not represent the variability of suction pressures used in different clinical settings. Limited Scope of Fluids: Although the study used four standardized viscosities, it did not account for the full range of fluids that might be encountered in clinical practice, such as bile, thick mucus, or complex mixtures of bodily fluids. No Intubation Scenario: The study did not test the catheters in an intubation scenario, which is a common situation where effective suctioning is critical. Generalizability: The results, while statistically significant, are based on a specific set of conditions and may not be directly applicable to all clinical environments without further validation. Discussion: The Ultimate Suction Tool: The DuCanto catheter significantly outperformed both the Yankauer and standard suction catheters, showing statistically significant improvements in suction rates across all four fluid viscosity types. This data suggests that the DuCanto catheter is a far superior suction device. Beyond its impre...
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