Prehospital Intubation Research Articles

Outcomes in Seriously Head-Injured Patients Undergoing Pre-Hospital Tracheal Intubation vs. Emergency Department Tracheal Intubation

Background: The optimal treatment of major head injuries in the resuscitative phase of care post-injury has yet to be determined. This study measured the effect on mortality of pre-hospital intubation (PHI) vs. emergency department in tubation (EDI) of patients suffering serious head injury. Methods: In the single emergency medical services system for this Canadian province, we used a population-based trauma database, conventional logistic regression (with and without the use of a propensity score to control for selection effect bias) to evaluate the effect of PHI vs. EDI on in-hospital mortality. Inclusion criteria were age ≥ 16 years, serious head injury (Abbreviated Injury Score ≥ 3, non-penetrating trauma) and resuscitative intubation (PHI or EDI). Results: Over 5 years, 283 patients (2000-2005) met inclusion crite ria. Conventional unconditional logistic regression modelled on mortality with “PHI vs. EDI” as the intervention of interest showed an odds ratio of 2.015 (95% CI 1.062 3.825) for improved survival if these patients were intubated in the emergency department rather than in the pre-hospital phase of care. A propensity score adjustment demonstrated a similar but more conservative point estimate (OR 1.727, 95% CI: 0.993 3.004). Conclusions: This observational study demonstrated a survival advantage with EDI (versus PHI) in seriously head-injured patients in a mature, province-wide emergency medical services system.

Year in review 2012: Critical Care - out-of-hospital cardiac arrest and trauma

In 2012 Critical Care published many articles pertaining to the resuscitation of out-of-hospital cardiac arrest and trauma. In this review, we summarize several of these articles, including those regarding advances in resuscitation techniques and methods. We examine articles pertaining to prehospital endotracheal intubation, the use of specialized devices for cardiopulmonary resuscitation and policies regarding transport destinations for both cardiac arrest and trauma patients. Articles on the predictors of outcome in both pediatric and adult populations are evaluated, including articles on the effects of obesity on survival from hemorrhage and pediatric outcomes from traumatic cardiac arrest. The effects of the type and volume of resuscitation fluids for both adult and pediatric patients are discussed, as are the factors contributing to hypothermia in trauma patients.

Analysis of prehospital endotracheal intubation performed by emergency physicians: retrospective survey of a single emergency medical center in Japan

Advanced airway management in the prehospital setting is a serious issue in Japan because emergency medical technicians are not authorized to perform such management, whereas physicians-who are authorized to perform advanced airway management-do not usually engage in prehospital emergency medical activity. The purpose of this investigation was to investigate the success rate for endotracheal intubation (ETI) procedures and other methods of airway management employed by physicians in the prehospital setting in a single institution, as well as to examine the risk factors associated with difficult or failed endotracheal intubation (D/F ETI). We performed a retrospective survey of patients treated in the prehospital setting by emergency physicians of the Hyogo Emergency Medical Center from 2004 to 2011. Patients were divided into two groups: a cardiopulmonary arrest (CPA) group and a non-CPA group. Data on cases of D/F ETI were obtained, and risk factors for these two groups were identified using univariate and statistical analysis. During the investigation period, ETI was attempted in the prehospital setting on 742 eligible patients; in 30 (4.04%) of these cases, the attempts at ETI proved difficult or failed. Of those 30 patients, 13 patients received a surgical airway (attempts to provide a surgical airway failed in two patients), a blind ETI was performed in four, a video-assisted airway device was used in another four, and esophageal intubation was performed in four patients. Bag-valve ventilation alone was performed in one patient. The incidence of D/F ETI was higher in the non-CPA group than in the CPA group (6.27 vs. 2.63%: p<0.05). Facial or neck injury was a risk factor for D/F ETI in the prehospital setting in the CPA group (odds ratio 7.855; 95% CI 1.754-36.293: p=0.042). On the other hand, no risk factors for D/F ETI in the prehospital setting in the non-CPA group were identified. The success rate for ETI performed by physicians in the prehospital setting at a single emergency medical center was high, and the incidence of D/F ETI was 4.31%. The success rate for ETI in the CPA group was greater than that in the non-CPA group.

Incidence of transient hypoxia during pre‐hospital rapid sequence intubation by anaesthesiologists

Pre-hospital tracheal intubation (TI) is an important but difficult procedure with the potential to produce hypoxaemia. The aim of this study was to determine the incidence of desaturation episodes during out-of-hospital rapid sequence induction (RSI) and TI by the medical team of a German Helicopter Emergency Medical Service (HEMS). We performed a prospective study at HEMS 'CHRISTOPH 22'. TI was performed as RSI according to a standard protocol. Desaturation was defined as a reduction in SpO(2) below 90% or a reduction of more than 10% from baseline SpO(2) when initial values were less than 90%. The RSI/TI manoeuvre was attempted in 150 patients [107 male (71.3%); median age 40 years (IQR 21-61); overall success rate 100%]. The incidence of desaturation episodes was 13.3% with a median duration of 50 sec. (IQR 30-92) and a median SpO(2) decrease of 24 ± 10%. Upon hospital admission, all patients had SpO(2) values ≥ 96%. In the desaturation group the duration of successful TI was significantly longer [median 85 sec. (IQR 60-119) vs. median 63 sec. (IQR 48-70); P < 0.01], and the number of patients with a baseline SpO(2) ≥ 90% was significantly lower (65.0% vs. 88.5%; P < 0.01). Among patients with difficult to manage airway, those with desaturation were significantly younger, and technical problems were significantly more frequent. The incidence of episodes of desaturation during pre-hospital RSI/TI at HEMS Ulm is relatively low, and the duration of such episodes is short.

Abstract 308: A Preoxygenation “Bundle” Decreases Desaturation Events and Improves Intubation Success in Air Medical Rapid Sequence Intubation

Introduction: Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and has been associated with increased morbidity and mortality. Preoxygenation with positive-pressure ventilation (PPV) may delay the onset of desaturation. However, PPV may not be used aggressively with emergency RSI due to concern for gastric insufflation precipitating regurgitation and aspiration events. Objective: To evaluate an aggressive preoxygenation protocol with regard to desaturation events during air medical RSI. Methods: The RSI protocol used in our air medical program airway training model was modified to employ several interventions designed to optimize preoxygenation prior to initial laryngoscopy. These included: two-person bag-valve-mask (BVM) ventilation, “two-thumbs-up” hand positioning on the mask, correct application of cricoid pressure, aggressive use of nasopharyngeal and oropharyngeal airways, small-volume assisted ventilation prior to administration of RSI medications, and large-volume ventilation following sedation/paralysis but prior to the initial laryngoscopy attempt. This algorithm identified a target SpO2 value of at least 93% based on a previous investigation. Desaturation events [decrease in SpO2 to &lt;90% or a continued decrease by at least 2% if initial SpO2 value was &lt;90%] were identified using physiologic data exported from hand held oximeter-capnometer devices. The incidence of desaturation events was established over a 2-year period prior to and the subsequent 2-year period following implementation of these algorithm changes. Results: A total of 155 RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the two years prior to the algorithm changes to 28% in the first year and 14% in the second year following implementation (chi-square test for trend p&lt;0.01). In addition, the intubation success rate increased from 94% to 97% following implementation of the protocol. There were no reports of major aspiration events during the study period. Conclusions: An aggressive preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success during air medical RSI without increasing aspiration events.

Prehospital non-drug assisted intubation for adult trauma patients with a Glasgow Coma Score less than 9

ObjectivesPrehospital airway management for adult trauma patients remains controversial. We sought to review the frequency that paramedic non-drug assisted intubation or attempted intubation is performed for trauma patients in Ontario,...

Prehospital endotracheal intubation; need for routine cuff pressure measurement?

In endotracheal intubation, a secured airway includes an insufflated cuff distal to the vocal cords. High cuff pressures may lead to major complications occurring after a short period of time....

Prehospital management of severe traumatic brain injury

Prehospital management affects long-term outcome of patients with severe traumatic brain injury (TBI). This article reviews the current concepts and ongoing controversies of prehospital treatment of severe TBI. Prehospital management focuses on the prevention of secondary brain injury and rapid transport to a neurotrauma center for definitive diagnosis and life- as well as brain-saving emergency treatment such as decompressive craniotomy. There is a broad consensus that adequate airway management, prevention of hypoxia, hypocapnia or hypercapnia, prevention of hypotension and control of hemorrhage represent preclinical therapeutic modalities that may contribute to improved survival in severe TBI. The precise role of prehospital endotracheal intubation, osmotic agents and early therapeutic hypothermia needs to be clarified in the context of time required for transportation, local infrastructure, geographical factors and availability of experienced emergency teams. Prehospital management of TBI remains challenging. There are no universal objectives suitable to all patients. Randomized, controlled clinical trials are necessary for developing optimal protocols for paramedic and physician emergency medical teams.

Factors associated with difficult intubation in prehospital emergency medicine

When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71-14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04-6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2-4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P<0.01). For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.

Ketamine-induced Catalepsy during Adult Sedation in the Emergency Department

BackgroundKetamine continues to rise in popularity for procedural sedation in the Emergency Department (ED) for both adult and pediatric patients. The medication has a good safety profile and is well tolerated in the majority of patients. However, the Emergency Physician should be aware of the full range of side-effects that may be encountered, so as to best anticipate and prepare for potential complications. ObjectivesWe describe two cases of catalepsy (muscle hypertonia with dissociation) in patients undergoing sedation with ketamine. Case ReportIn the first case, a patient presented to the ED after a prehospital awake nasal intubation for an exacerbation of chronic obstructive pulmonary disease. After sedation with ketamine, he was extubated and transitioned to bi-level positive pressure ventilation. Shortly after receiving ketamine, he exhibited severe muscular hypertonia of the upper extremities with facial grimacing. A second patient underwent ketamine sedation for reduction of a shoulder dislocation. After medication administration, he exhibited full body muscular hypertonicity, interfering briefly with the procedure. In both patients, catalepsy resolved spontaneously. ConclusionsKetamine-induced catalepsy is a self-limited side-effect that has the potential to interfere with procedures performed under sedation.

Still making the case against prehospital intubation

Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage. The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock. There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04). Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.

Prehospital intubation for traumatic brain injury: do it correctly, or not at all

Prehospital intubation for traumatic brain injury: do it correctly, or not at all

Effects of physician-based emergency medical service dispatch in severe traumatic brain injury on prehospital run time

IntroductionPrehospital care by physician-based helicopter emergency medical services (P-HEMS) may prolong total prehospital run time. This has raised an issue of debate about the benefits of these services in traumatic brain injury (TBI). We therefore investigated the effects of P-HEMS dispatch on prehospital run time and outcome in severe TBI. MethodsPrehospital run times of 497 patients with severe TBI who were solely treated by a paramedic EMS (n=125) or an EMS/P-HEMS combination (n=372) were retrospectively analyzed. Other study parameters included the injury severity score (ISS), Glasgow Coma Scale (GCS), prehospital endotracheal intubation and predicted and observed outcome rates. ResultsPatients who received P-HEMS care were younger and had higher ISS values than solely EMS-treated patients (10%; P=0.04). The overall prehospital run time was 74±54min, with similar out-of-hospital times for EMS and P-HEMS treated patients. Prehospital endotracheal intubation was more frequently performed in the P-HEMS group (88%) than in the EMS group (35%; P<0.001). The prehospital run time for intubated patients was similar for P-HEMS (66 (51–80)min) and EMS-treated patients (59 (41–88min). Unexpectedly, mortality probability scores and observed outcome scores were less favourable for EMS-treated patients when compared to patients treated by P-HEMS. ConclusionP-HEMS dispatch does not increase prehospital run times in severe TBI, while it assures prehospital intubation of TBI patients by a well-trained physician. Our data however suggest that a subgroup of the most severely injured patients received prehospital care by an EMS, while international guidelines recommend advanced life support by a physician-based EMS in these cases.

Postintubation hemodynamic effects of intravenous lidocaine in severe traumatic brain injury

BackgroundThe risks of intravenous (IV) lidocaine before rapid sequence induction (RSI) have become a great concern. No study has investigated the hemodynamic effects of IV lidocaine during endotracheal intubation in patients with severe traumatic brain injury. ObjectiveWe investigated whether the use of IV lidocaine before RSI was associated with postintubation hemodynamic changes in patients with severe traumatic brain injury. MethodsIn this retrospective cohort study, adults who presented with isolated traumatic brain injury and definite intracranial hemorrhage were included. Patients who presented with other major injuries received prehospital intubation, had initial mean arterial pressure (MAP) less than 70 mm Hg, and/or had incomplete medical records were excluded. ResultsA total of 101 patients (82.2% men; mean age, 48.6 ± 19.6 years) were enrolled. Forty-six patients received IV lidocaine in addition to RSI before intubation (group 1), and 55 received RSI without IV lidocaine before intubation (group 2). There were no significant intergroup differences in baseline characteristics, the number of RSI doses, or the RSI dose used, with the exception of sex, diagnosis of subarachnoid hemorrhage, and diagnosis of subdural hemorrhage. Our results demonstrated no significant intergroup differences in MAP changes or the proportion of patients with hypotension (MAP <70 mm Hg) after intubation. Intravenous lidocaine remained unrelated to significant hypotension after adjusting for variables by logistic regression analysis. ConclusionIntravenous lidocaine in addition to RSI before endotracheal intubation was not associated with significant hemodynamic changes in patients with severe traumatic brain injury.

Impact of prehospital mode of transport after severe injury

There is ongoing controversy about the relative effectiveness of air medical versus ground transportation for severely injured patients. In some systems, air medical crews may provide a higher level of care but may require longer transport times. We sought to evaluate the impact of mode of transport on outcome based on analysis of data from two randomized trials of prehospital hypertonic resuscitation. Injured patients were enrolled based on prehospital evidence of hypovolemic shock (systolic blood pressure ≤70 mm Hg or systolic blood pressure = 71-90 mm Hg with heart rate ≥108 bpm) or severe traumatic brain injury (TBI; Glasgow Coma Scale score ≤8). Patient demographics, injury severity, and physiology were compared based on mode of transport. Multivariate logistic regression was used to determine the impact of mode of transport on 24-hour and 28-day survival for all patients and 6-month extended Glasgow Outcome Scale for patients with TBI, adjusting for differences in injury severity. Included were 2,049 patients, of which 703 (34%) were transported by air. Patients transported by air were more severely injured (mean Injury Severity Score, 30.3 vs. 22.8; p < 0.001), more likely to be in the TBI cohort (70% vs. 55.4%; p < 0.001), and more likely blunt mechanism (94.0% vs. 78.1%; p < 0.001). Patients transported by air had higher rates of prehospital intubation (81% vs. 36%; p < 0.001), received more intravenous fluids (mean 1.3 L vs. 0.8 L; p < 0.001), and had longer prehospital times (mean 76.1 minutes vs. 43.5 minutes; p < 0.001). Adjusted analysis revealed no significant impact of mode of transport on survival or 6-month neurologic outcome (air transport-28-day survival: odds ratio, 1.11; 95% confidence interval, 0.82-1.51; 6-month extended Glasgow Outcome Scale score ≤4: odds ratio, 0.94; 95% confidence interval, 0.68-1.31). There was no difference in the adjusted clinical outcome according to mode of transport. However, air medical transported more severely injured patients with more advanced life support procedures and longer prehospital time. III.

Latency of Pulse Oximetry Signal with Use of Digital Probes Associated with Inappropriate Extubation during Prehospital Rapid Sequence Intubation in Head Injury Patients: Case Examples

BackgroundEndotracheal intubation remains the definitive skill needed for airway management of both medical and surgical patients treated in the prehospital and hospital arenas. Subsequently, rapid sequence intubation (RSI) protocols have been established for various first-line emergency service providers. Because RSI results in the paralysis of skeletal muscles, with a subsequent period of apnea and an increased potential for oxygen desaturation, the accuracy of pulse oximetry (SpO2) data is critical in guiding pre-oxygenation efforts and indicating abandonment of intubation attempts to avoid hypoxic injury. Latency of up to 120 s has been demonstrated in conditions producing peripheral vasoconstriction. The influence of peripheral oximetry on the decision-making process during the establishment of a definitive airway has not, to our knowledge, been previously investigated in the prehospital setting. ObjectiveTo demonstrate how signal latency may manifest itself as a perceived oxygen desaturation with a subsequent premature abortion of a primary RSI attempt or erroneous extubation. Case ExamplesWe document endotracheal extubation associated with pulse oximetry signal latency during prehospital RSI with the use of digital SpO2 probes. Two case examples are presented that are taken from a retrospective analysis of pre-hospital RSI data recorded by the City of San Diego Emergency Medical Services. ConclusionTo avoid the possibility of mistaking oximetry signal latency for oxygen desaturation during pre-hospital RSI, we propose a conservative approach of aggressive pre-oxygenation to SpO2 values≥94%, and the use of quantitative continuous capnometry for decision-making regarding whether the endotracheal tube is correctly placed. In cases of hypoxemia despite a properly placed tube, focus should be turned to other causes of post intubation hypoxemia.

Abnormal End-Tidal Carbon Dioxide Levels on Emergency Department Arrival in Adult and Pediatric Intubated Patients

Background. The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished. Objectives. The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO2) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO2 levels on ED arrival and mortality. Methods. This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO2 measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO2 measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO2 value (<30 mmHg or >45 mmHg). The secondary outcome was mortality. Results. One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO2 value was 32 mmHg (IQR 27, 38 mmHg), range 18–80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO2 values, including 37 (39%, 95% CI 29%, 49%) with low ETCO2 levels and nine (9%, 95% CI 4%, 17%) with high ETCO2 levels. Death was higher in those trauma patients with abnormal ETCO2 levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO2 levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26.4), p = 0.004. Conclusion. Nearly half of all patients transported by prehospital providers had abnormal ETCO2 measurements on initial ED presentation, suggesting an area for potential improvement. Trauma patients with abnormal initial ETCO2 levels were more likely to die.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.MethodsWe conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.ResultsFrom 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).ConclusionsThis comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Chapter 3. Indications for intracranial pressure monitoring

Chapter 3. Indications for intracranial pressure monitoring

Variables Associated with Successful Intubation Attempts Using Video Laryngoscopy: A Preliminary Report in a Helicopter Emergency Medical Service

Background. Multiple studies have demonstrated varying rates of successful endotracheal intubation (ETI). Until the application of video laryngoscopy, little information regarding prehospital intubation could be analyzed objectively by individuals other than the provider performing the ETI. Objective. To evaluate the association of variables recorded during video laryngoscopy and successful ETI attempts, defined as placing the endotracheal tube in the trachea. Methods. We retrospectively reviewed intubations performed by a single helicopter emergency medical service (HEMS) using a video larygoscope from March 1, 2010, to October 1, 2010. All videos were de-identified and analyzed by a single researcher. Time intervals (e.g., attempt time) and intubation process variables (e.g., Cormack-Lehane [C-L] view) were abstracted from all videos. Time intervals were begun when the laryngoscope blade passed the lips and entered the oral cavity (entry). We describe variables using means and standard deviations (continuous), medians with interquartile ranges (ordinal), and percentages with 95% confidence intervals (categorical). We then looked at univariate associations between these variables and ETI success using logistic regression. Results. We recorded 116 intubations during the study period. Twenty-nine recordings were either incomplete (n = 26) or of insufficient quality for analysis (n = 3). The remaining 87 videos represented 87 different patients with a total of 102 attempts at laryngoscopy. Thirty-six providers performed 64 cases, with the majority of providers (n = 21) performing only one intubation. The first-pass success rate in this series was 76% (n = 66), with 98% success within three attempts. Successful ETI attempts had lower entry–to–percentage of glottic opening (POGO) times (16.6 sec vs. 32.1 sec, p = 0.013), entry–to–first view of the endotracheal tube or entry-to-tube times (17.6 sec vs. 27.4 sec, p = 0.04), higher POGO scores (76 vs. 39, p < 0.001), and a lower C-L view (one vs. three, p < 0.001). Recognized esophageal intubation was more likely to occur during unsuccessful ETI attempts (43% vs. 8%, p < 0.001). Conclusion. Video laryngoscopy can measure multiple components of ETI performance. Successful ETI attempts have significantly shorter entry-to-POGO times and entry-to-tube times, obtain better views of the glottic opening (POGO and C-L view), and have a lower incidence of recognized esophageal intubation.