Ketamine Only Intubation, Good or Bad?

Rapid sequence intubation is not always the safest default when laryngoscopy may fail or physiology is fragile. Ketamine-only breathing intubation sits between topicalized awake intubation and RSI, preserving spontaneous respirations while trading away some intubating conditions and certainty.

Awake Intubation Decision Framework

• Three awake techniques: ED awake intubation now falls into three buckets: sedative-facilitated intubation, topicalized awake intubation, and ketamine-only breathing intubation, each balancing cooperation, safety, and ease differently.
• Paralysis paradox: When you fear laryngoscopy may fail, avoiding paralysis feels safer, yet paralysis often improves the view and first-pass conditions; that tension is the core airway decision we unpack in the episode.
• Video laryngoscopy shift: With video laryngoscopy, obtaining a view is less often the limiting step than it was with direct laryngoscopy, so the incremental benefit of paralytics may be smaller in some patients.
• Difficult airway indications: Awake strategies matter most in anatomically difficult and physiologically difficult airways, where preserving spontaneous breathing can be more valuable than perfect intubating conditions.
• Topicalized awake advantages: Topicalized awake intubation is the safest option all else equal because the patient stays awake and breathing, and lidocaine-based topical anesthesia avoids hemodynamic hits from induction drugs.

Ketamine Only Breathing Intubation

• KOBI sweet spot: Ketamine-only breathing intubation is built for patients who need dissociation but may not tolerate apnea, offering a practical bridge when full topicalized awake intubation is unrealistic in the ED.
• Core tradeoff: KOBI preserves spontaneous respirations and patient tolerance of laryngoscopy, but it is not as safe as true topicalized awake intubation and does not create the same conditions as RSI.
• Headline ketamine dose: Dissociative ketamine is the key requirement, with many clinicians targeting 1.5 to 2 mg/kg IV to ensure complete dissociation rather than drifting into inadequate sedation.
• Prepared paralysis backup: Ketamine can trigger jaw rigidity or laryngospasm, so a paralytic should be drawn up and immediately available before starting; the rescue sequencing is worth hearing in the chapter.
• Topicalization adjunct: Adding local anesthetic topicalization to ketamine may improve tolerance and may reduce vomiting risk when you have the bandwidth, a practical nuance we get into on the show.
• Evidence caution: KOBI is a useful airway tool, but the evidence base remains limited and contested, making patient selection and operator readiness more important than enthusiasm for the technique.

References

1. Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. West J Emerg Med. 2019;20(3):466-471.  PMID: 31123547
2. Driver BE, Reardon RF, Mosier J. Ketamine as Monotherapy in Difficult Airways Is Not Ready for Prime Time. West J Emerg Med. 2019;20(6):970-971. Published 2019 Oct 17. PMID: 31738726
3. Merelman AH, Perlmutter MC, Strayer RJ. Author Response to: "Ketamine as Monotherapy in Difficult Airways Is Not Ready for Prime Time". West J Emerg Med. 2019;20(6):972-973. Published 2019 Oct 17.  PMID: 31738727
4. Driver BE, Prekker ME, Reardon RF, et al. Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department. J Emerg Med. 2021;60(3):265-272. PMID: 33308912
5. Perlmutter MC, Merelman AH, Strayer RJ. Response to "Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department". J Emerg Med. 2021;60(6):816-817. PMID: 34147233