Written by Aaron Lacy
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Patients undergoing emergency tracheal intubation (ETI) had a major adverse event one-third of the time and 28-day mortality of almost 50%.
ETI is still dangerous
ETI is one of the highest-risk procedures performed in the ED, with studies citing adverse events in up to 40% of cases.
This study from Brazil looked at peri-intubation adverse events and 28-day mortality in 2,846 adult patients from 18 different EDs. Those in cardiac arrest or who were intubated electively were excluded.
Peri-intubation adverse events (within 30 minutes of the procedure) occurred in 919 (32.3%) of cases. New hemodynamic instability (systolic arterial pressure <65mmHg!; requirement or need for increase in vasopressors; need for fluid bolus >15 ml/kg) occurred in 20% of patients. Severe hypoxemia (peripheral saturation <80%) occurred in 12.5% of cases. Cardiac arrest occurred in 3.5% of cases. The primary outcome, 28-day mortality, was high, at 45.1%.
How will this change my practice?
This study highlights that ETI is high risk. I will continue to hone my intubation skills and prepare for a physiologically or anatomically difficult airway every time. The 28-day mortality approached 50%, and patients who had a major adverse event had a much higher chance of dying within 28 days (aHR 1.43, 95%CI 1.26-1.62; p<0.001).
However, success on the first attempt has a much lower rate of adverse events (aOR 0.52, 95%CI 0.41-0.65; p<0.001), and subsequently, death. No ETI can be taken lightly, and I will continue to have that mentality in this high-risk procedure.
Source
Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study. Crit Care. 2025 Apr 17;29(1):155. doi: 10.1186/s13054-025-05392-w. PMID: 40247381
