🩺 THIS WEEK IN EM
Ketamine vs. Etomidate for RSI: The Mortality Difference Never Showed Up — But the Hemodynamics Did
For years, the ketamine-versus-etomidate argument for RSI in critically ill adults ran on physiology, vibes, and selective memory. Etomidate was the villain because of transient adrenal suppression. Ketamine became the hemodynamic darling because it was supposed to preserve blood pressure in the crashing patient.
Then the randomized trial finally showed up.
In a large multicenter trial of 2,365 critically ill adults undergoing tracheal intubation, ketamine and etomidate produced essentially identical 28-day in-hospital mortality: 28.1% with ketamine versus 29.1% with etomidate. So the old fear that etomidate’s adrenal effects would translate into worse real-world outcomes did not hold up.
But the more interesting finding was during the intubation itself: cardiovascular collapse was more common with ketamine — 22.1% versus 17.0% with etomidate. That difference was driven by hypotension and increased vasopressor needs. In other words, the drug many people reached for because it felt “hemodynamically safer” did worse on the hemodynamic outcome that actually matters in the room.
This does not mean ketamine is dead. It means the reflexive assumption that ketamine is the safer induction agent for the sickest patients is no longer supported. If you are intubating someone in septic shock or any catecholamine-depleted state, etomidate is not the bad guy people made it out to be.
Bottom line: Ketamine and etomidate have similar mortality outcomes for RSI in critically ill adults, but ketamine caused more peri-intubation cardiovascular collapse. Etomidate remains a very reasonable induction choice.
Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2026;394:1608-1620.
Pulmonary Embolism Got a New Language in 2026 — and It Actually Helps
The old PE vocabulary — massive, submassive, low-risk — is finally getting retired. Good. It was never as precise as people pretended.
The new 2026 multisociety guideline replaces that system with an A-through-E framework that maps more cleanly to actual bedside decisions.
Category A is incidental or asymptomatic PE. Category B is symptomatic but low severity — the sort of patient who may be appropriate for early discharge. Category C includes patients with higher severity scores, RV dysfunction, biomarker elevation, or both, and generally points you toward hospitalization. Categories D and E capture patients with incipient or established cardiopulmonary failure, where advanced therapies become more relevant.
The practical change for the ED is this: if a patient has low-risk features, no RV strain, and no biomarker evidence of trouble, the guideline gives you more explicit support for discharge than most of us were trained with. On the other end, it sharpens the line for when hospitalization and PE response–type escalation should happen.
PESI and sPESI still matter. Hestia still matters. The difference is that the guideline finally integrates them into a clearer disposition-and-therapy structure instead of leaving you with mushy labels and a vague sense of dread.
Bottom line: The new PE guideline is more than a terminology update. It gives a clearer framework for who can go home, who needs admission, and who needs escalation.
2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. Circulation. 2026.
POCUS in Undifferentiated Shock: Still One of the Highest-Value Things You Can Do in the First Five Minutes
None of this is new, but it keeps being re-proven: if your hypotensive patient is crashing in front of you, bedside ultrasound is one of the fastest ways to stop being stupid on purpose.
Structured POCUS protocols — especially RUSH — remain most useful when they answer immediate resuscitation questions: is the pump failing, is the tank empty or overloaded, and are the pipes obstructed or ruptured? In practical terms, you are looking for depressed cardiac function, pericardial effusion, RV strain, a plethoric or collapsing IVC, free fluid, B-lines, pneumothorax, or a big angry aorta.
The yield is especially high in obstructive shock. Tamponade, massive PE, tension physiology — these are the diagnoses where ultrasound can change your management before the labs are even back. That matters. A lactate does not tell you the right next move nearly as often as a decent cardiac window does.
The usual caveat still applies: POCUS is operator-dependent. That is not a reason to delay using it. It is a reason to use it more deliberately and more consistently. Protocol beats random wandering. A three-minute RUSH exam done early is better than a beautiful but late ultrasound after you’ve already committed to the wrong resuscitation path.
Bottom line: In undifferentiated shock, use POCUS early and use it systematically. RUSH belongs in the first few minutes, not as an optional add-on after the workup is mostly over.
Basmaji J, Arntfield R, Desai K, et al. The Impact of Point-of-Care Ultrasound-Guided Resuscitation on Clinical Outcomes in Patients With Shock: A Systematic Review and Meta-Analysis. Crit Care Med. 2024;52(11):1661-1673.
Yoshida T, Yoshida T, Noma H, et al. Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis. Crit Care. 2023;27(1):200.
⚡ Shift Pearl
Etomidate’s adrenal suppression is real. The apocalypse from it probably isn’t.
The new RSI trial does not mean etomidate suddenly has no endocrine effects. It means those effects did not translate into worse mortality in a large randomized comparison. If your septic patient needs stress-dose steroids later, give them. But don’t let ghost stories about etomidate push you into a less stable induction choice in the moment.
🔭 Next Week
• SGLT2 inhibitors in acute heart failure: Is there a role for starting them in the ED before discharge?
• IV vs. oral antibiotics for cellulitis and skin infections: The evidence for outpatient oral therapy is stronger than you think
• High-sensitivity troponin 0/1-hour pathways: How confident can you really be, and who still needs observation?
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.