Contributor: Travis Barlock, MD

Educational Pearls:

First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma.

• Complication rate for patients intubated on the first pass is 14%

• Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt

How to improve likelihood of first-pass success:

• Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71%

• Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study cites a success rate in these patients of 96% with a bougie, compared to 82% without

• Use a Checklist mnemonic (SOAPME)

• Suction – On, ready, and within reach

• Oxygen – Patient is preoxygenated

• Adjuncts – Oral/nasal adjuncts and BVM ready

• Positioning - Patient positioned properly; consider obesity, using semi-Fowler/head-up positioning

• Medications – Rapid sequence intubation (RSI), sedation, vasopressor, and other medications prepared as necessary

• Equipment – Laryngoscope (blade), tube, bougie/stylet, syringe, scalpel/cric kit, others ready as necessary

References

1. Sakles, J.C., Chiu, S., Mosier, J., Walker, C. and Stolz, U. (2013), The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med, 20: 71-78. https://doi.org/10.1111/acem.12055

2. Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2023;389(5). doi:https://doi.org/10.1056/nejmoa2301601

3. Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496

4. ‌Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278

5. Turner, Joseph S et al. "Feasibility of upright patient positioning and intubation success rates At two academic EDs." The American journal of emergency medicine vol. 35,7 (2017): 986-992. doi:10.1016/j.ajem.2017.02.011

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P

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