Improving the First-attempt Success with Hyperangulated Videolaryngoscopy in Emergency Settings

BackgroundRecent trials showed that video laryngoscopy (VL) did not yield higher first-attempt tracheal intubation success rate than direct laryngoscopy (DL) and was associated with higher rates of complications. Tracheal intubation can be more challenging in the general ward than in the intensive care unit. This study aimed to investigate which laryngoscopy mode is associated with higher first-attempt intubation success in a general ward.MethodsThis is a retrospective study of tracheal intubations conducted at a tertiary academic hospital. This analysis included all intubations performed by the medical emergency team in the general ward during a 48-month period.ResultsFor the 958 included patients, the initial laryngoscopy mode was video laryngoscopy in 493 (52%) and direct laryngoscopy in 465 patients (48%). The overall first-attempt success rate was 69% (664 patients). The first-attempt success rate was higher with VL (79%; 391/493) than with DL (59%; 273/465, p < 0.001). The first-attempt intubation success rate was higher among experienced operators (83%; 266/319) than among inexperienced operators (62%; 398/639, p < 0.001). In multivariate logistic regression analyses, VL, pre-intubation heart rate, pre-intubation SpO2 > 80%, a non-predicted difficult airway, experienced operator, and Cormack–Lehane grade were associated with first-attempt intubation success in the general ward. Over all intubation-related complications were not different between two groups (27% for VL vs. 25% for DL). However, incidence of a post-intubation SpO2 < 80% was higher with VL than with DL (4% vs. 1%, p = 0.005), and in-hospital mortality was also higher (53.8% vs. 43%, p = 0.001).ConclusionIn a general ward setting, the first-attempt intubation success rate was higher with video laryngoscopy than with direct laryngoscopy. However, video laryngoscopy did not reduce intubation-related complications. Furthers trials on best way to perform intubation in the emergency settings are required.

Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium. To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations. Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016. Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624). The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis. Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group. Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate. ClinicalTrials.gov Identifier: NCT02000674.

Effect of hyperangulated videolaryngoscopy on first-attempt success in tracheal intubations: A systematic review and meta-analysis.

Background: Airway obstruction and failed tracheal intubation are major contributors to morbidity and mortality in surgical and critical care settings. Orotracheal intubation remains a cornerstone of airway management in both elective and emergency situations. Among various video laryngoscopes (VLs), the McGrath and C-MAC devices are widely used, but comparative data on their performance remains inconclusive from Pakistan. Aim: To compare the efficacy of McGrath and C-MAC video laryngoscopes in adult patients undergoing elective orotracheal intubation. Methodology: This single-center, randomized controlled trial was conducted in the Doctors Hospital and Medical Centre, Lahore from 20 March 2025 to 20 June 2025. Patients were classified as American Society of Anesthesiologists (ASA) physical status I to IV, and scheduled for elective surgery requiring orotracheal intubation. Patients were randomly allocated to either the McGrath group (n = 50) or the C-MAC group (n = 50). The intubation was performed using standardized induction protocols. Primary outcome was the first-pass intubation success rate. Secondary outcomes included number of attempts, glottic view, ease of intubation, hemodynamic responses, and occurrence of complications. Data were analyzed using SPSS version 28.0 (IBM Corp), with significance set at p &lt; 0.05. Results: First-attempt success was significantly higher in the C-MAC group (92%) compared to the McGrath group (70%) (p = 0.006). Ease of intubation was also superior in the C-MAC group, with 86% of cases rated as ≥8 on the NRS versus 60% in the McGrath group (p = 0.003). Although overall success rates (C-MAC 98%, McGrath 92%) and complications (C-MAC 2%, McGrath 10%) differed, these were not statistically significant. Glottic visualization was marginally better with the C-MAC (Grade 1 view in 88% vs. 80%), but the difference was not significant (p = 0.218). Hemodynamic parameters remained within safe ranges in both groups, with no significant intergroup variation. Conclusion: it demonstrated that the C-MAC video laryngoscope is associated with a significantly higher first-pass intubation success rate and greater ease of intubation compared to the McGrath in adult patients undergoing elective orotracheal intubation. Further research is warranted to assess their performance in difficult airway and emergency settings.

Rapid sequence intubation in emergency settings may involve opioid pretreatment to blunt hemodynamic responses during laryngoscopy and intubation; however, opioids may lead to postintubation hypotension, increasing morbidity and mortality. Global clinical practice varies significantly, reflecting uncertainty about opioids' benefits and risks. Our goal was to evaluate the association between opioid pretreatment and hemodynamic instability, focusing on postintubation hypotension in adult patients undergoing emergency intubation. We performed a systematic review of randomized controlled trials and observational studies comparing opioid administration vs. no opioids before adult emergency intubations. Searches included Cochrane, Embase, Medline, Scopus, and Web of Science databases until November 2024. Elective intubations were excluded. Eight (6708 patients) studies met criteria. The primary outcome was postintubation hypotension, variably defined across studies. Secondary outcomes included hypoxemia, first-attempt success, cardiac arrest, and vasopressor use. Independent reviewers conducted data extraction, risk-of-bias assessments, and certainty evaluation. Results were qualitatively synthesized. Among 6708 (2757 opioids and 3951 controls) patients, postintubation hypotension incidence varied widely (risk differences: -12.5% favoring opioids to +13.2% favoring controls). The single low-risk randomized study reported opioids increased hypotension (risk difference: 13%, odds ratio: 2.15, 95% confidence interval: 1.22-3.78). Observational studies yielded inconsistent results. Secondary outcomes showed no consistent differences. Evidence certainty was very low because of risk of bias, inconsistency, and imprecision. Current evidence regarding opioid pretreatment effect on postintubation hypotension risk during emergency intubation is limited and conflicting.

Background: Personal protective equipment used for protection of healthcare workers in the combat against Severe Acute Respiratory Syndrome Coronavirus 2 pandemic is in limited supply worldwide at present – 2020. Use of barrier enclosure during endotracheal intubation can potentially act as a cost-effective adjunct to minimize risks of transmitting the infection to healthcare workers. However, there is concern that the enclosure itself will act as a barrier to the intubation procedure in the emergency settings. Objective: To evaluate the negative effect of barrier enclosure (an aerosol box) on the performance of video-assisted intubation in a manikin Methods: A total of 41 Emergency Department doctors from a local hospital were recruited to perform intubation in a manikin simulating normal and more difficult airways (Cormack-Lehane grades I and IIb) with and without the box. The primary outcome was time of successful intubation. The secondary outcomes were first-attempt success rate, number of successful attempts, need of adjuncts, dental injury and ease of intubation as perceived by the participants. Results: The aerosol box had no significant negative effect on the time of successful intubation (p = 0.630 (Grade I airway) and p = 0.436 (Grade IIb airway)), first-attempt success rate, number of successful attempts, need of adjuncts or dental injury. Participants subjectively reported extra yet minor challenges during intubation in the presence of the box. Conclusion: Within limits of the pilot study, the aerosol box had no statistical significant difference but an increasing trend of prolonged endotracheal intubation interval in the Grade IIb airway and negative impact on first-pass success, and could potentially be used to protect healthcare workers during the aerosol-generating intubation procedure.

Background: Effective airway management remains a cornerstone of emergency and surgical care, especially in patients with anticipated or unanticipated difficult airways. The choice of device can significantly impact patient outcomes. Among the available options, the endotracheal tube (ETT) and laryngeal mask airway (LMA) are widely used. However, the clinical superiority of one over the other in difficult airway scenarios continues to be a topic of ongoing investigation, particularly in resource-constrained or emergency settings. Objective: To compare the effectiveness of ETT and LMA in managing difficult airways in terms of insertion time, success rate, and complication frequency. Methods: A cross-sectional study was conducted over six months across three tertiary hospitals, enrolling 130 adult patients aged 18 years and above who required general anesthesia and met the criteria for difficult intubation. Patients were allocated to receive either an ETT or LMA based on the attending anesthesiologist’s clinical judgment. Insertion time was recorded in seconds, and any complications such as sore throat, airway trauma, or laryngospasm were documented. Data were analyzed using IBM SPSS Version 29. An independent t-test and chi-square test were applied to determine statistical significance, with p &lt; 0.05 considered significant. Results: The mean insertion time for LMA was significantly shorter at 54.3 seconds compared to 183.6 seconds for ETT (p &lt; 0.001). The first-attempt success rate was higher for LMA (84.6%) than ETT (30.8%) (p &lt; 0.001). Complications were notably fewer with LMA (23.1%) than with ETT (53.8%) (p = 0.002), suggesting improved safety and ease of use with LMA in difficult airway cases. Conclusion: LMA proved to be a faster, safer, and more effective option compared to ETT in the management of difficult airways, especially in scenarios demanding rapid airway control. Further large-scale studies are recommended for broader validation.

The aim of this study was to review the evidence comparing the traditional landmark technique with the ultrasound-guided cannulation technique for peripheral intravenous catheter insertion in emergency department patients with difficult intravenous access (DIVA). A systematic review and meta-analysis was performed in accordance with PRISMA-guidelines. The protocol was prospectively registered on PROSPERO (CRD42024573146). PubMed, Cochrane, EMBASE, and CINAHL were searched between August 2024 and April 2025. Bias assessment was performed using Revised Cochrane Risk of Bias tool for randomized trials. Randomized controlled trials of emergency department patients with DIVA were eligible for inclusion. The primary outcome was first-attempt success rate. Secondary outcomes were number of intravenous insertion-attempts and patient satisfaction. A random-effects meta-analysis plot using DerSimonian and Laird method was used to calculate risk ratio (RR) of the primary outcome measure. Eight randomized controlled trials with a total of 1477 emergency department patients were included in the review and 940 patients in the meta-analysis. The use of ultrasound in the emergency setting was associated with a higher first-attempt success rate (RR, 1.80; 95% CI, 1.18-2.73; p < 0.01). Secondary outcomes; number of attempts and patient satisfaction had heterogenous results. The small number of studies included in the meta-analysis is a limitation. Ultrasound guided cannulation improved the first-attempt success rate compared to the traditional landmark technique in patients with DIVA. Future policy makers should consider the use of ultrasound guidance as the first choice in order to reduce unnecessary insertion attempts in emergency department patients.

Videolaryngoscopy for all intubations: Is direct laryngoscopy obsolete?

Background Ultrasound-guided subclavian vein catheterization is crucial for central venous access, but the choice between the supraclavicular and infraclavicular approaches lacks comprehensive comparison. This study addresses this gap by conducting a prospective observational analysis of both techniques. The supraclavicular method accesses the vein from above the clavicle while the infraclavicular targets it below. Our model-driven approach aims to elucidate the procedural nuances, success rates, and complications associated with each method. The findings intend to equip clinicians with evidence-based insights, facilitating informed decision-making for improved procedural outcomes in ultrasound-guided subclavian vein catheterization. Aim and objective This study aims to comprehensively compare the supraclavicular and infraclavicular approaches in ultrasound-guided subclavian vein catheterization, evaluating the procedural minutiae, potential advantages, and challenges associated with each technique. Employing a prospective observational methodology, our objective is to provide evidence-based insights for approaches in ultrasound-guided subclavian vein catheterization, evaluating procedural nuances, success rates, and complications during the procedure. Methods In this prospective investigation, 276 patients aged between 20 and 55 years were randomly assigned to two groups: 143 patients in the supraclavicular group and 133 patients in the infraclavicular group. Specifically, patients admitted for elective surgery necessitating postoperative ICU care were considered. The study assessed various variables, including success rate, time required for venous visualization, venous puncture, catheterization, total procedure duration, and incidence of mechanical complications, to facilitate group comparisons. Results The mean procedural time was shorter in the supraclavicular group compared to the infraclavicular group, with durations of 2 minutes and 2 seconds versus 3 minutes and 40 seconds, respectively (95% CI). This difference was statistically significant. Similarly, the mean durations for venous visualization, venous puncture, and venous catheterization were also shorter in the supraclavicular group, and these differences were statistically significant. Both groups achieved a 100% success rate, with the first attempt success rate being higher in the supraclavicular subclavian vein group. Conclusion The findings of this study demonstrate a statistically significant advantage in favor of the supraclavicular approach for ultrasound-guided subclavian vein catheterization. The shorter mean procedural time, as well as durations for venous visualization, puncture, and catheterization, emphasize the efficiency of the supraclavicular technique. The consistently achieved 100% success rate, coupled with a higher first-attempt success rate, further underscores the proficiency of the supraclavicular subclavian vein group. These results collectively suggest that the supraclavicular approach is not only time-efficient but also superior in terms of successful central line placement, making it a promising choice for both emergency and critical care settings.

Point-of-care ultrasound (POCUS) is a bedside diagnostic tool clinicians use to provide immediate insights and guide therapeutic interventions. It has become increasingly significant in pediatric emergency departments (EDs) for diagnosing conditions, managing critical scenarios, and guiding procedures due to its portability, ease of use, and lack of radiation. This study aims to systematically review and analyze the efficacy of POCUS compared to conventional diagnostic methods in pediatric emergency settings. A literature search was conducted across PubMed, SCOPUS, Web of Science, Embase, and Cochrane Library up to February 2025. The inclusion criteria were pediatric patients aged 1 month to 18 years in EDs, with studies comparing POCUS to conventional methods. Primary outcomes included first-attempt procedural success and overall success rates. Secondary outcomes included time to procedure completion, mean number of attempts, hospitalization rates, and discharge rates. Data analysis was conducted in R employing a random-effects model, with dichotomous data analyzed as risk ratio (RR) and 95% confidence interval (CI), and continuous data as unbiased standardized mean difference (SMD). Statistical significance was defined at p < 0.05. Eighteen randomized controlled trials involving 2264 patients met the inclusion criteria. POCUS significantly improved first-attempt success (RR = 1.25; 95% CI: 1.09-1.43). The overall procedural success showed a significant benefit with POCUS (RR = 1.12; 95% CI: 1.03-1.22). However, no significant differences were noted in the time to procedure completion, number of attempts for a successful procedure, and rates of hospitalization and discharge to home. POCUS significantly improves first-attempt and overall procedural success rates in pediatric emergency settings, although it does not significantly reduce procedure times or the number of attempts. These findings underscore the importance of integrating POCUS into pediatric emergency care to enhance diagnostic accuracy and procedural success, though further research is needed to optimize its implementation across different age groups and procedures.

BackgroundIn emergency settings, difficult intubations often occur unexpectedly despite pre-intubation assessments. Traditional glottic view scoring systems for direct laryngoscope may not apply to video laryngoscopy. With video laryngoscopy, the vertical location of the glottis on the monitor can be clearly defined. If the glottis location is associated with intubation difficulty, it could serve as a simple indicator for anticipating intubation challenges. This study aimed to investigate the relationship between the glottis screen location during video laryngoscopy-guided intubation and the success and timing of the first-attempt intubation.MethodsWe retrospectively analyzed laryngoscopy recordings from adult intubations in the emergency department of a tertiary teaching hospital in Chiayi, Taiwan, using the C-MAC video laryngoscope between March 2020 and April 2023. The vertical screen location of the vocal cords, determined by the arytenoid cartilage position after laryngeal blade engagement, was categorized into upper and lower locations for analysis. The primary outcome was first-attempt intubation success within 90 s, analyzed using Kaplan-Meier survival curves and multivariable Cox proportional hazard analysis.ResultsAmong 209 laryngoscopy records, 113 had the arytenoid in the lower field of view and 96 in the upper field. Kaplan-Meier analysis showed a significantly lower cumulative success rate for intubations with a higher arytenoid location (log-rank test, P < 0.001). Multivariable Cox models, adjusted for factors like modified Cormack-Lehane grade, blade tip engagement, and other intubation findings, confirmed the arytenoid’s location as an independent predictor of successful intubation within 90 s, with an adjusted hazard ratio of 0.55 (95% confidence interval, 0.38–0.79) for the upper location group compared to the lower (P < 0.001).ConclusionsA higher screen location of the vocal cords after blade engagement is associated with reduced first-attempt intubation success. Assessing glottis location during video laryngoscopy intubation provides a quick method to anticipate intubation challenges.

The aim of this study was to examine the success rates, longevity, and complications of ultrasound-guided peripheral intravenous lines (USgPIVs) placed in a pediatric emergency department. The study analyzed 300 USgPIV attempts in an urban tertiary-care pediatric emergency department. Data regarding USgPIV placement were collected from a 1-page form completed by the clinician placing the USgPIV. The time and reason for USgPIV removal were extracted from the medical record for patients with USgPIVs admitted to the hospital. A Kaplan-Meier survival analysis was performed. This study demonstrated a success rate of 68% and 87% for the first and second attempts with USgPIV. Fifty-five percent of patients had 1 or more prior traditional intravenous access attempt. Most USgPIVs placed on patients admitted to the hospital were removed because they were no longer needed (101/160). We calculated a Kaplan-Meier median survival of 143 hours (6 days; interquartile range, 68-246 hours). The failure rate at 48 hours was 25%. Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.

IntroductionFirst-pass success (FPS) in emergency tracheal intubation is a key quality metric linked to fewer intubation-related complications, but data from low-income settings are limited. This study aimed to measure FPS and identify intubation-related complications in two tertiary hospitals in Addis Ababa, Ethiopia.MethodsWe conducted a prospective, cross-sectional observational study of consecutive emergency and ICU tracheal intubations at Tikur Anbessa Specialized Hospital (TASH) and Zewditu Memorial Hospital (ZMH) from May to October 2024. Patients aged 13 years or older undergoing emergency intubations were included. Online tool was developed to collect key variables from clinicians. The primary outcome was FPS (successful endotracheal tube placement on the first laryngoscope insertion). Bivariate analyses and multivariable logistic regression were used to identify independent predictors; adjusted odds ratios (aOR) with 95% confidence intervals (CI) were reported.ResultsA total of 112 intubations were analyzed. Median age of patients was 37.5 years (IQR 25–55); 62.5% were male. Hypoxic respiratory failure was the predominant indication (68.8%). Direct laryngoscopy was used in all cases; the most common induction strategy was ketamine (50/112 [44.6%]) with succinylcholine (67/112 [59.8%]) as the neuromuscular blocking agent. FPS was 64.3% (72/112). Additional successes occurred on the second (25.0%), third (8.0%), and ≥ 4 attempts (2.7%). One or more complications occurred in 42 out of the 112 cases (37.5%; 95% CI 28.5–46.5%), highlighting a substantial immediate adverse-event burden; cardiovascular instability occurred in 22.3%, cardiac arrest in 5.4%, and death within one hour in 2.7%. On adjusted analysis, operator training level and airway visualization were the strongest predictors: Year-II residents (aOR 46.81; 95% CI 3.03–722.72; p = 0.006) and Year-III residents (aOR 406.30; 95% CI 13.72–12,033.01; p < 0.001) had markedly higher odds of FPS compared to Year-I residents. Intubations without anticipated difficulty were more likely to succeed (aOR 10.74; 95% CI 1.01–114.45; p = 0.049). A Cormack–Lehane grade III view predicted failure (aOR 0.005; 95% CI 0.000–0.828; p = 0.042), while an abducted vocal cord favored success (aOR 23.96; 95% CI 2.93–195.76; p = 0.003).ConclusionFPS in these Addis Ababa hospitals (Tikur Anbessa Specialized Hospital and Zewditu Memorial Hospital) was 64.3%, a level we consider suboptimal compared with commonly cited benchmarks of ≥ 80%. This is lower than pooled benchmarks reported from large high-income country series (~ 79–84%) but within the range reported in some low- and middle-income settings. Operator experience and airway visualization were the dominant determinants of one-pass success. Given the high immediate complication rate (37.5%), targeted supervised training, anticipation of difficult anatomy, and prioritized expansion of airway adjuncts (e.g., bougie, phased introduction of video laryngoscopy and capnography) should be implemented to improve FPS and reduce harm in resource-limited emergency settings.

Airway obstruction is the second leading cause of preventable death on the battlefield. Video laryngoscopy has improved airway management in the emergency setting for several decades, and technology continues to improve. Current technology in the supply chain is cost-prohibitive to incorporate at Role 1 facilities, which is where many intubations occur by novice intubators. The i-view is a novel video laryngoscopy device that is handheld, inexpensive, and disposable. The aim of this study was to determine if the i-view is suitable based on performance assessments by physician assistant trainees and survey feedback. We prospectively enrolled physician assistant students at the Interservice Physician Assistant Program at Joint Base San Antonio-Fort Sam Houston. We provided them structured training on how to use the device, and then, a board-certified emergency medicine physician or certified registered nurse anesthetist assessed their intubations performed on a SynDaver mannequin model. We surveyed the participants afterward. We enrolled 60 Interservice Physician Assistant Program students. Most participants were male (75%) with a median age of 32 years. Service affiliations included Army (50%), Navy (23%), Air Force (18%), and Coast Guard (8%). Most (70%) had previous deployment experience. All the participants successfully cannulated the mannequins and 98% achieved first-attempt success. Most participants (78%) reported a grade 1 view. On postprocedure survey, 91% strongly agreed with using this device in the deployed setting and 89% strongly agreed with finding it easy to use. All physician assistant trainees successfully and rapidly performed endotracheal intubation using the disposable i-view video laryngoscope. Study participants rated the device as easy to use and desirable for deployment. Further research is necessary to validate this novel device in the clinical setting before recommending dissemination to the deployed military medical force sets, kits, and outfits.