Ketamine-only breathing intubation

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Sorry, we couldn't find any posts. Please try a different search.

Ketamine-only breathing intubation(KOBI), is a technique where Ketamine(+/- topical local anaesthetic) is used to facilitate intubation in patients that may not be able to tolerate traditional Rapid Sequence Intubation(RSI)

3 Approaches to Ketamine use in intubation

  1. Ketamine as the induction agent in normal RSI: It shows haemodynamic stability and a long duration of action
  2. Ketamine in Delayed Sequence intubation: It facilitates pre-oxygenation in the un-cooperative patient. Dosages of 1-2mg/kg IV can be used. When pre-oxygenation has been achieved, a paralytic agent can then be used, as in traditional RSI.
  3. Ketamine as the dissociative agent, with or without topical anaesthetic. An example of its use here, is in the patient exposed to a fire, that has carbonatious sputum. An airway needs to be established, but there is concern about the state of swelling in the airway. Ketamine is used to control the patient, whilst the cords are viewed, preferably by video laryngoscopy. See this case with images below. There are other indications for it.

What is Ketamine-only breathing intubation(KOBI)…and why would we use it?

Ketamine in a dissociative dose of 1-2mg/kg IV has both an amnesic effect and dampens the effect of painful stimuli. At this same time the airway reflexes are maintained. We don’t call it awake intubation as we might with a topical anaesthetic-only approach, as the patient is not awake.

Merelman et al(1) describe 4 situations where the patient can benefit from KOBI:

  1. Patients with a high oxygen deficit, where even a short duration of apnoea, can have dire consequences. This is classically your patient with pneumonia or ARDS, where aggressive oxygenation attempts with mask or NIV cannot get the saturations up above 95%.
    • In traditional RSI, that time after paralytics where apnoea occurs and no oxygen is being delivered, can result in cardiac arrest.
    • Apnoeic oxygenation is usually of no great benefit in these patients.
    • There are techniques for using traditional RSI in these situations, however Ketamine may be an alternative.
    • (In deep sedation, Ketamine will reduce minute ventilation, but that is preferred to apnoea.)
  2. In patients where awake intubation would normally be required, but due to lack of skills or time etc, this approach cannot be used.
  3. In the acidotic patient with high minute ventilation (DKA, toxic alcohol, lactic acidosis). Using spontaneous respiration may be a way of decreasing the risk associated with peri-intubation decompensation.
    • These are the patients that will have sudden cardiac arrest on intubation with traditional RSI.
  4. The hypotensive patient. Although Merelman(1) discusses this type of patient, the approach would be to resuscitate aggressively BEFORE and intubation attempt is made, so that the chance of hypotension is reduced.
    • In traditional RSI, when the patient becomes apnoeic and then transitions from negative to positive pressure, there is a decreased in venous return leading to potential cardiovascular collapse.

What can make Ketamine-only intubation difficult?

MUSCLE RIGIDITY: This can occur with Ketamine. The solution is to give Midazolam, but this can then cause hypotension etc..

LARYNGOSPASM: This certainly has been shown to occur with Ketamine. Some PEEP may assist, however in most cases paralytics will be needed. The problem here will be that this patient with high oxygen requirements has now gone into laryngospasm and then needs to wait for the paralytic to work. Not a good scenario.

VOMITING: Airway reflexes are not totally abolished, so it may lead to coughing and gagging.

An example where it can be used

A patient is brought into the ED after being rescued from a house fire. He has no visible burns, but his nasal hairs and eyebrows are singed and he has carbonaceous sputum. His voice sounds altered(although we aren’t sure), so we are concerned about potential airway swelling. The carbonaceous sputum is an indication for early intubation, but we are not sure of the state of the airway and how difficult intubation might be. We used Ketamine and topical anaesthetic with video laryngoscopy, as a means of visualisation and to facilitate intubation.

Ketamine is used to sedate/dissociate the patient (1mg/kg IV). Atomised local anaesthetic is used on the airway to dampen the gag response and allow us to progressively get a better look. The airway is suctioned and although the cords are seen to be slightly swollen, intubation is certainly possible. The patient has been breathing spontaneously this whole time. A paralytic agent is given and the tube is passed under direct vision. The tube might also have been passed, under direct vision, with no paralytic agent, however to avoid laryngospasm and any other complications it was decided to paralyse the patient. See the images below.

References

  1. Merelman A et al. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. West J Emerg Med 2019;20(3):466-471
Posted in ,

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

65 Comments

  1. Proxies Usa on 31/08/2021 at 10:30 am

    Best Private Proxy Store – https://DreamProxies.com – Order Private Proxies and also Obtain 50 OFF as well as Totally free Proxies!

  2. Your Private Proxies on 01/09/2021 at 11:39 am

    some truly interesting points you have written.

  3. Buy Usa Proxies on 02/09/2021 at 11:31 am

    Just what I was searching for, regards for putting up.

  4. Quality Proxies on 09/09/2021 at 5:07 am

    I would also like to convey that most of those who find themselves devoid of health insurance are generally students, self-employed and those that are jobless. More than half on the uninsured are under the age of Thirty five. They do not think they are in need of health insurance since they are young as well as healthy. Their own income is generally spent on property, food, and also entertainment. Some people that do go to work either complete or as a hobby are not made available insurance via their jobs so they go without due to rising expense of health insurance in the us. Thanks for the concepts you share through this web site.

  5. SEO on 20/09/2021 at 2:06 am

    Wow, incredible blog format! How long have you ever been running a blog for? you made running a blog glance easy. The whole look of your web site is wonderful, as smartly as the content!!

  6. linkedin growing on 27/09/2021 at 7:21 am

    Wow, wonderful blog format! How long have you been running a blog for? you made running a blog look easy. The full look of your web site is wonderful, as well as the content!!

  7. Charissa on 06/10/2021 at 7:13 am

    What’s up mates, its enormous paragraph regarding teachingand
    completely explained, keep it up all the time.

  8. https://ug-plast.ru/ on 06/10/2021 at 7:14 am

    Superb site you have here but I was curious about if you knew of any discussion boards that cover the same topics discussed here?

    I’d really love to be a part of community where I can get suggestions from
    other experienced individuals that share the same interest.
    If you have any recommendations, please let me know.
    Appreciate it!

    My web blog … weight loss plateau – https://ug-plast.ru/,

  9. better sex tips for women on 06/10/2021 at 7:15 am

    Its not my first time to pay a visit this web
    site, i am visiting this website dailly and take pleasant data from here daily.

    Here is my blog: better sex tips for women

  10. Thank you, I’ve just been looking for information approximately this topic for ages and yours is the greatest I’ve came
    upon till now. However, what about the conclusion? Are you sure about the source?

    My web page … best facial skin (http://www.fles.hlc.edu.tw/userinfo.php?uid=1374546)

  11. how to get healthy skin on 06/10/2021 at 7:22 am

    I don’t even understand how to get healthy skin I stopped up here, however I thought this put up was once great.
    I do not recognise who you might be however certainly you’re going
    to a famous blogger for those who aren’t already 😉 Cheers!

  12. better sex in marriage on 06/10/2021 at 7:36 am

    Yeah bookmaking this wasn’t a risky decision outstanding
    post!

    my website – better sex in marriage

  13. build muscle diet on 06/10/2021 at 7:39 am

    I carry on listening to the reports speak about receiving free online grant applications so I
    have been looking around for the best site to get one. Could
    you tell me please, where could i get some?

    my homepage – build muscle diet

  14. eating healthy on 06/10/2021 at 7:42 am

    Thank you a lot for sharing this with all folks
    you actually realize what you are speaking about!
    Bookmarked. Kindly additionally talk over with my website =).
    We can have a link alternate arrangement between us!

    Have a look at my web page … eating healthy

  15. lower back surgery on 06/10/2021 at 7:51 am

    What’s up, I desire to subscribe for this website to get latest updates, thus where
    can i do it please help out.

    My homepage … lower back surgery

  16. slot ios on 06/10/2021 at 8:07 am

    I really love your site.. Pleasant colors & theme. Did you create this web
    site yourself? Please reply back as I’m hoping to create my own website and would love to learn where you got this from or what the theme is
    called. Cheers!

  17. slot android on 06/10/2021 at 8:08 am

    When I initially left a comment I appear to have clicked the
    -Notify me when new comments are added- checkbox and now whenever a comment is added I recieve 4 emails with the
    same comment. Is there an easy method you can remove
    me from that service? Cheers!

  18. beautiful skin on 06/10/2021 at 8:09 am

    wonderful post, very informative. I wonder why the opposite
    specialists of this sector don’t realize this. You must continue your writing.
    I’m sure, you’ve a huge readers’ base already!

    Review my homepage: beautiful skin

  19. drug crime attorney on 06/10/2021 at 8:21 am

    I want to to thank you for this very good read!!
    I definitely enjoyed every little bit of it. I
    have you saved as a favorite to check out new stuff you post…

    Feel free to surf to my web page drug crime attorney

  20. growing inside on 06/10/2021 at 8:39 am

    I get pleasure from, result in I discovered just what I was having a
    look for. You have ended my 4 day long hunt! God Bless you man. Have a nice day.
    Bye

    my page: growing inside

  21. holiday weight loss on 06/10/2021 at 8:45 am

    Simply a smiling visitor here to share the love (:, btw great design.

    my blog post; holiday weight loss

  22. try hemp on 06/10/2021 at 9:03 am

    It’s truly very difficult in this full of activity life to listen news on Television, thus I simply use world
    wide web for that purpose, and take the most recent information.

    my page; try hemp

  23. fotosombra.com.br on 06/10/2021 at 9:08 am

    It?s difficult to find educated people for this topic, however, you seem like you know
    what you?re talking about! Thanks

    My web page; acne treatment reviews (fotosombra.com.br)

  24. Very nice pattern and wonderful content material, nothing at all else
    we require :D.

    Also visit my homepage – eating habits (https://www.mhes.tyc.edu.tw/userinfo.php?uid=4089831)

  25. having sex on 06/10/2021 at 9:30 am

    This excellent website really has all of the info I needed about
    this subject and didn’t know who to ask.

    Feel free to visit my web site … having sex

  26. fat loss diets on 06/10/2021 at 9:38 am

    Wow, amazing weblog format! How lengthy have you ever been blogging for?
    you made blogging glance easy. The total look of your website is fantastic, let alone the content!

    Review my website … fat loss diets

  27. carb nite solution on 06/10/2021 at 9:40 am

    Hello, i feel that i noticed you visited my website so i came to ?return the want?.I’m attempting to find
    things to enhance my website!I assume its good enough to use some of your
    ideas!!

    my web page :: carb nite solution

  28. flaxseed oil on 06/10/2021 at 9:41 am

    I got what you intend,saved to my bookmarks, very decent site.

    my web page: flaxseed oil

  29. Amy on 06/10/2021 at 10:01 am

    Thank you for the auspicious writeup. It in fact was a enjoyment account it.
    Glance complex to more delivered agreeable from you! However, how can we keep in touch?

  30. carb days on 06/10/2021 at 10:06 am

    Greate post. Keep posting such kind of info on your blog.
    Im really impressed by your site.[X-N-E-W-L-I-N-S-P-I-N-X]Hey there, You’ve done an incredible job.
    I’ll definitely digg it and individually recommend to my friends.
    I am sure they will be benefited from this website.

    Have a look at my web blog carb days

  31. Darrell on 06/10/2021 at 10:15 am

    Hello, everything is going perfectly here and ofcourse every
    one is sharing information, that’s in fact fine, keep up writing.

  32. sex position on 06/10/2021 at 10:26 am

    I wanted to check up and allow you to know how , a great deal I liked discovering your web site today.
    I will consider it the honor to do things at my business office and be able to utilize tips provided on your blog and also get involved in visitors’ responses like this.
    Should a sex position
    associated with guest author become on offer at your end,
    remember to let me know.

  33. produce healthy on 06/10/2021 at 10:28 am

    Right here is the right webpage for anyone who would like
    to understand this topic. You know so much its almost hard to argue
    with you (not that I personally would want to…HaHa).
    You certainly put a new spin on a topic which has been written about for ages.
    Wonderful stuff, just wonderful!

    Also visit my website – produce healthy

  34. wrinkle skin care on 06/10/2021 at 10:29 am

    As I site possessor I believe the content material here is rattling wonderful , appreciate it for your hard work.
    You should keep it up forever! Good Luck.

    Feel free to visit my page … wrinkle skin care

  35. belly fat supplements on 06/10/2021 at 10:56 am

    I am regular visitor, how are you everybody?
    This article posted at this site is genuinely good.

    Here is my page … belly fat supplements

  36. Franklin on 06/10/2021 at 11:06 am

    Howdy! Do you use Twitter? I’d like to follow you if that would be okay.
    I’m definitely enjoying your blog and look forward to new posts.

  37. pure hemp seed oil on 06/10/2021 at 11:34 am

    Hello, yeah this article is actually nice and I have
    learned lot of things from it on the topic of blogging.
    thanks.

    my web site – pure hemp seed oil

  38. Alonzo on 06/10/2021 at 12:35 pm

    This blog was… how do you say it? Relevant!! Finally
    I have found something which helped me. Thanks a lot!

  39. www.fles.hlc.edu.tw on 06/10/2021 at 12:36 pm

    Saved as a favorite, I love your website!

    my blog – low-carb diets (http://www.fles.hlc.edu.tw)

  40. judi slot uang asli on 06/10/2021 at 1:45 pm

    I blog frequently and I seriously thank you for your content.

    This great article has truly peaked my interest.

    I am going to take a note of your blog and keep checking
    for new details about once a week. I opted in for your
    Feed as well.

  41. impact carbs on 06/10/2021 at 2:01 pm

    Why visitors still make use of to read news papers when in this technological world the whole thing is accessible on net?

    my webpage – impact carbs

  42. omega 3 fish oil bulk size ordering on 06/10/2021 at 2:03 pm

    I needed to create you one very little remark to finally thank you again about the splendid tricks you’ve provided on this
    page. This is quite seriously generous with people like you to
    offer freely all that most of us could possibly have advertised for an e book to end up making some cash on their own, precisely given that you might have tried it if you considered necessary.
    The strategies also acted as a good way to comprehend other people have a similar keenness
    much like my personal own to grasp a good deal more pertaining to this problem.
    I’m certain there are a lot more pleasurable periods in the future for folks who read your
    site.

    Also visit my web blog: omega 3 fish oil bulk size ordering

  43. www.aniene.net on 06/10/2021 at 2:19 pm

    Hello, I believe your site could possibly be having web browser compatibility problems.
    Whenever I take a look at your blog in Safari, it looks fine however, if opening in Internet Explorer, it’s got some overlapping issues.
    I merely wanted to give you a quick heads up! Aside
    from that, excellent site!

    my web blog low-carb diet (http://www.aniene.net)

  44. best sex in marriage on 06/10/2021 at 4:07 pm

    Wow, that’s what I was exploring for, what a stuff!

    existing here at this webpage, thanks admin of this web page.

    Review my blog … best sex in marriage

  45. poor posture on 06/10/2021 at 4:35 pm

    Appreciate it for this wondrous post, I am glad I noticed this
    website on yahoo.

    Visit my blog: poor posture

  46. http://www.fotosombra.com.br on 06/10/2021 at 6:31 pm

    What’s up, after reading this remarkable piece of writing i am as well happy to
    share my experience here with friends.

    My site eat healthy; http://www.fotosombra.com.br,

  47. slot Ios on 06/10/2021 at 7:34 pm

    Hi, all the time i used to check web site posts here early in the morning, because i like to find out more and more.

  48. slot android on 07/10/2021 at 1:27 am

    Highly descriptive blog, I liked that bit. Will there be a part 2?

  49. Judi slot uang asli on 07/10/2021 at 4:14 am

    Article writing is also a excitement, if you know afterward you can write if not it is complex to write.

  50. judi slot uang asli on 07/10/2021 at 4:56 am

    What’s Happening i am new to this, I stumbled upon this
    I have discovered It absolutely useful and it has helped me out loads.
    I am hoping to contribute & aid other customers like its
    helped me. Good job.

  51. Donna on 07/10/2021 at 7:05 am

    Hey very interesting blog!

  52. Velma on 07/10/2021 at 7:12 am

    Its such as you learn my mind! You seem to grasp a lot approximately this, such as you wrote the
    book in it or something. I feel that you simply can do with a few percent to force the message house a bit, but other than that, this is great blog.
    A fantastic read. I will certainly be back.

  53. carslot88 agen judi slot on 07/10/2021 at 9:32 am

    Wow that was odd. I just wrote an extremely long comment but after I clicked submit my comment didn’t show up.
    Grrrr… well I’m not writing all that over again. Anyway, just wanted
    to say excellent blog!

  54. Jackie on 07/10/2021 at 11:26 am

    I do trust all the concepts you’ve presented for your post.
    They are very convincing and can definitely work. Still, the posts are
    too short for novices. May just you please extend
    them a bit from subsequent time? Thank you for the
    post.

  55. carslot88 agen judi slot on 08/10/2021 at 12:55 pm

    I used to be suggested this web site by way of
    my cousin. I’m not sure whether or not this
    post is written by means of him as nobody else know such precise approximately my
    difficulty. You’re amazing! Thank you!

  56. https://www.petads.com.au/ on 09/10/2021 at 2:49 am

    Terrific work! This is the kind of info that are supposed to be shared across the
    internet. Shame on the search engines for not positioning this post higher!
    Come on over and visit my website . Thank you =)

  57. slot android on 10/10/2021 at 8:55 am

    I was recommended this website by my cousin. I am not sure whether this post is written by him as no one else know such
    detailed about my trouble. You’re amazing! Thanks!

  58. Slot Android on 10/10/2021 at 2:01 pm

    If you are going for most excellent contents like me, just go to see this web page every day because it presents feature contents, thanks

  59. click here on 12/10/2021 at 4:00 am

    I loved as much as you’ll receive carried out right here. The sketch is tasteful, your authored material stylish. nonetheless, you command get bought an impatience over that you wish be delivering the following. unwell unquestionably come further formerly again since exactly the same nearly a lot often inside case you shield this hike.

  60. Jaime on 12/10/2021 at 8:19 am

    This web site is known as a stroll-via for all the data you wanted about this and didnt know who to ask. Glimpse here, and youll positively uncover it.

  61. williams-sonoma.capitalone.com activate on 12/10/2021 at 12:20 pm

    Thanks – Enjoyed this article, can I set it up so I receive an update sent in an email every time you write a fresh update?

  62. Ketamine-only breathing intubation – Resus
    ayyvxxolov
    yyvxxolov http://www.gm48l139omn172ar5y5lgk6l419z0m1zs.org/
    [url=http://www.gm48l139omn172ar5y5lgk6l419z0m1zs.org/]uyyvxxolov[/url]

  63. start.watchown.tv/activate on 12/10/2021 at 11:14 pm

    hi!,I love your writing so so much! percentage we keep in touch more about your post on AOL? I require a specialist in this area to unravel my problem. May be that’s you! Having a look ahead to see you.

  64. https://activate.nbcnews.com on 14/10/2021 at 2:37 am

    You possess an exceptional inventiveness. Your website writing talents are without a doubt effective. Gratitudes for uploading web content via the internet and training your users.

  65. click here on 14/10/2021 at 9:13 am

    I’m really enjoying the design and layout of your site. It’s a very easy on the eyes which makes it much more pleasant for me to come here and visit more often. Did you hire out a developer to create your theme? Outstanding work!

Leave a Comment