Ketamine Awake Intubation: Outcomes of Difficult Airway Management in the Emergency Department

Tuesday, March 24, 2026

8:45 AM - 9:45 AM Central Time

Location: Connections Central - RST 11

Hayley Scott, MD (she/her/hers)

State University of New York At Stony Brook University Hospital, New York

Disclosure(s): No relevant financial relationship(s) to disclose.
SM

Somair Malik, MD MBA

Physician
Stony Brook University Hospital

Disclosure information not submitted.
MT

Matthew Tanzi, MD

Physician
Stony Brook University Hospital

Disclosure information not submitted.
Jillian Leibowitz, DO (she/her/hers)

State University of New York At Stony Brook University Hospital, New York

Disclosure(s): No relevant financial relationship(s) to disclose.
JT

Justin Townsend, DO

Physician
Stony Brook University Hospital

Disclosure information not submitted.
JC

Joseph Corcoran, MD

Physician
Stony Brook University Hospital

Disclosure information not submitted.
DR

David Rapoport, MD

Physician
Stony Brook University Hospital

Disclosure information not submitted.
RN

Richard Niyazov, DO

Physician
Stony Brook University Hospital

Disclosure information not submitted.
CK

Candice King, NP

Nurse Practitioner
Stony Brook University Hospital

Disclosure information not submitted.
SW

Scott Weingart, MD, FCCM

Physician
Stony Brook University Medical Center State University of New York

Disclosure information not submitted.

Introduction: Rapid Sequence Intubation (RSI) has long been the standard method for emergency department (ED) intubation. RSI uses contemporaneous administration of a sedative and paralytic, but poses risks in patients with hemodynamic instability, difficult airways, and those at risk of decompensation when apneic. Ketamine Awake Intubation (KAI) has emerged as an alternative in high-risk scenarios, offering dissociative sedation without paralysis, while preserving respiratory drive and airway reflexes. Despite growing interest, standardized protocols and comparative data remain limited. The aim of our study is to describe our protocol for optimizing KAI and compare peri-intubation complications to the standard, RSI.

Methods: We performed a retrospective analysis of a prospectively maintained airway registry from a large tertiary care ED from June 2017 to December 2024. Using the registry, we reviewed KAI and RSI cases to track peri-intubation complications and first pass success (FPS). Variables included demographics, technique, and predicted airway difficulty. The primary outcome included rate of peri-intubation cardiac arrest and desaturation events. Secondary outcomes included supraglottic airway use, cricothyrotomy rate, post-induction vomiting and FPS rates.

Results: A total of 2,178 patients were included: 114 in the KAI group and 2,064 in the RSI group. Desaturation events were more frequent with KAI (7.0% vs. 3.4%; RR 2.04, p = 0.064), though not statistically significant. Vomiting (0.9% vs. 0.5%, p = 0.45), cardiac arrest (0.9% vs. 0.6%, p = 0.42), and supraglottic airway use (0.9% vs. 1.8%, p = 0.72) were also not significantly different. Difficult airways were more common in the KAI group (77.2% vs. 18.7%; RR 4.13, p < 0.0001). FPS was lower in KAI (83.3% vs. 93.3%; RR 0.89, p = 0.0005), with higher second and third attempt rates (11.4% vs. 5.0%, p = 0.0083; 3.5% vs. 1.2%, p = 0.062).

Conclusions: Peri-intubation complications were similar between KAI and RSI, suggesting KAI is a viable alternative for high-risk patients, particularly those with difficult anatomy. However, lower FPS rates and more frequent multiple attempts highlight the need for experienced providers when performing KAI. Future prospective studies are needed to better define the role of KAI in anatomically difficult airways.