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Video Laryngoscopy and First-Pass Success in Trauma Airways

October 1, 2021

Written by Nickolas Srica

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The use of video laryngoscopy was associated with twice the odds of first-pass success in comparison to direct laryngoscopy for emergency department trauma intubations performed by emergency physicians.

Why does this matter?
Mastering the difficult airway is a prerequisite to being a good emergency physician. Trauma patients requiring intubation frequently have significant anatomic and physiologic reasons to be tough to intubate, including cervical spine collars, facial and airway trauma, soiled airways from vomit and blood, hemodynamic instability, and hypoxemia, just to name a few. Does video laryngoscopy (VL) improve our chances of first-pass success when compared to direct laryngoscopy (DL) in ED intubations in trauma patients?

A video is worth a thousand tubes, or something like that…
This was an observational study with secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). They looked specifically at trauma intubations and applied robust descriptive statistics for these patients at 23 academic EDs who participated in this registry between 2016 and 2018. Due to the potential for confounding, they also performed a subsequent analysis using propensity score matching to create balanced groups that matched patients with similar pre-intubation characteristics. All patients regardless of age were included in this study, and they only excluded trauma intubations done specifically at children’s hospitals (2 sites with 13 intubations). The first-pass success analysis only included intubations done by emergency or pediatric emergency physicians using VL or DL and rapid-sequence intubation (RSI) or no meds. The NEAR included 19,071 ED intubations during this timeframe, of which 23% (n=4,449) were for traumatic indications. Overall, first-pass success was 86.8% (95% CI 83.3%-90.3%) with 97.1% by the second attempt. When broken down by intubating device, VL had a 90% first-pass success rate compared to 79% for DL (11% difference, 95%CI 8%-13%). After propensity score matching, VL remained better (adjusted risk difference 11% (95%CI 8% to 14%) and OR 2.2 (95%CI 1.6 to 2.9). Esophageal intubations were also noted to be more frequent with DL compared to VL (1.5% versus 0.4%, 95%CI 0.4% to 2.0%). It’s worth noting that the highest rates of first-pass success were seen with Macintosh VL while also using a bougie (96%, 95%CI 91%-100%). This study further solidifies what my practice pattern has already become, which is to reach for video laryngoscopy (with bougie) whenever possible to maximize my chance of first-pass success. In an era when more and more of us are being trained from day one with VL, it is becoming more and more difficult to find a good reason not to utilize it.

Video Laryngoscopy is Associated with First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry. Annals of Emergency Medicine. 2021 August. doi: 10.1016/j.annemergmed.2021.07.115. 

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