HEAVEN criteria to predict difficult in-hospital rapid sequence intubation: a prospective single-centre observational study.

Airway management is a critical priority for HEMS teams, as failure to secure the airway remains a major determinant of mortality and long-term disability. The present study was designed to evaluate the variability of advanced airway management devices and medications availability across all HEMS units in Italy. In addition, crew composition and specialty training of HEMS personnel were assessed. As a whole, this survey aims at highlighting areas for improvement of airway management during HEMS operations. This observational cross-sectional study was carried out between May and September 2024. A web-based questionnaire was distributed to all active HEMS bases in Italy. The questionnaire consisted of two main sections: Section A addressed the availability of basic and advanced airway management equipment and medications, whereas Section B focused on crew characteristics, including number, role, experience, and training. A composite index to capture "airway preparedness"(API) was designed based on Difficult Airway Society 2025 guidelines. Selected items were assigned a weighted value and the final score ranged 0-40. Of 55 active HEMS bases, 48 completed the questionnaire (response rate: 87%). Manual ventilation devices, a direct laryngoscope, a complete set of Macintosh adult blades, an end-tidal CO₂ monitoring device, and supraglottic airway devices were consistently available. A videolaryngoscope was present in most bases (39, 81%). Either surgical or Seldinger cricothyroidotomy kits were present in 94%. Medications for rapid sequence intubation were universally available, although sugammadex was stocked in only 36 bases (75%). A physician was present in all surveyed units (100%). However, specific training in airway management was not provided in 37 bases (77%), and 44% did not require a minimum number of prior endotracheal intubations for new personnel. Only 13 bases (27%) reported the adoption of airway management guidelines for prehospital care. The mean ± SD national API was 25.7 ± 7.4, ranging from a regional mean of 37 ± 1.4 to a regional mean of 11.2 ± 5.3. The study demonstrated substantial heterogeneity in equipment, personnel background, and training across Italian HEMS bases. Although only few bases reported adherence to specific guidelines, the devices and medications recommended in the literature for the management of unexpected difficult airways were widely available.

Obesity is a global health challenge. An increasing number of patients with obesity are admitted to an intensive care unit. Airway management in these patients represents a unique challenge due to significant anatomical and physiological alterations. Increased adipose tissue in the face, cheeks, pharynx, hypopharynx, and neck narrows the upper airway, renders soft tissues more collapsible, and complicates airway management. In addition, the functional residual capacity is reduced, resulting in markedly shortened safe apnea time, contributing to severe hypoxemia during intubation. Non-invasive ventilation is effective in mitigating this risk and should be applied from pre-induction to laryngoscopy. Peri-intubation physiological optimization should include assessment of preload and cardiac contractility, with careful consideration of right ventricular strain. The transition from negative to positive intrathoracic pressure should be closely monitored, with cautious titration of positive end-expiratory pressure. Recognition of these anatomical and physiological challenges may prompt clinicians to consider awake intubation in selected patients. When rapid sequence induction is performed, both ketamine and etomidate are appropriate options; the choice between them should be guided by the clinical context, patient characteristics, local practice patterns and availability. Videolaryngoscopy increases the incidence of successful intubation on the first attempt and should be adopted routinely in the population with obesity. Several questions remain unanswered, including the safety and efficacy of pre-emptive vasopressor use to prevent post-intubation cardiovascular collapse and the optimal dosing of hypnotic agents to achieve ideal intubation conditions, while minimizing adverse events.

Etomidate, ketamine, and propofol are all used as induction agents for emergency tracheal intubation in critically ill adults but it remains uncertain which agent should be preferable. We searched MEDLINE and Embase (inception to December 2025) for randomized controlled trials comparing etomidate, ketamine, propofol, or ketamine-propofol combination (ketofol) for emergency or rapid sequence intubation in critically ill adults. We performed random-effects network meta-analysis using the frequentist framework. The primary outcome was short-term mortality (28-30day, or ICU/in-hospital mortality when unavailable). Secondary outcomes included cardiovascular collapse, post-induction hypotension, vasopressor use, first-pass intubation success, and peri-intubation cardiac arrest. Certainty of evidence was assessed using the CINeMA framework. Nine trials (4,672 patients, four treatments) were included. Ketamine and etomidate probably result in similar mortality (OR 0.96, 95% CI 0.80-1.16; [Formula: see text] = 30%; moderate certainty). Evidence for other mortality comparisons was very uncertain: ketamine vs propofol (OR 1.53, 0.80-2.93; 1 trial; low certainty) and etomidate vs propofol (OR 0.63, 0.32-1.24; indirect only; very low certainty). Compared with etomidate, ketamine probably increases cardiovascular collapse (OR 1.44, 1.20-1.71; moderate certainty) and may increase post-induction hypotension (OR 1.34, 1.07-1.68; low certainty) and peri-intubation vasopressor use (OR 1.45, 1.21-1.74; low certainty). There was probably little or no difference in first-pass intubation success or cardiac arrest. Etomidate and ketamine probably result in similar mortality, but confidence intervals are compatible with clinically important differences in either direction-ketamine probably causes more peri-intubation hemodynamic instability. Beyond one trial, no randomized evidence exists for propofol in emergency intubation of critically ill adults.

Introduction: Succinylcholine and rocuronium are neuromuscular blocking agents commonly used as paralytics in the emergency department (ED) during rapid sequence intubation. Prior studies have shown mixed results regarding the preferred agent aside from settings where there are contraindications. This study compares outcomes of death, myocardial infarction, and post-traumatic stress disorder for succinylcholine vs rocuronium when used in rapid sequence intubation using data from a large, multicenter database. Methods: In this retrospective study, we extracted 105 million patient records from 61 healthcare organizations in the United States from the TriNetX database between 2004–2023. Adults ≥ 18 years of age who underwent intubation on the same day as an ED visit and received succinylcholine or rocuronium with the hypnotic anesthetic etomidate were included. The outcomes evaluated were mortality and myocardial infarction within 60 days after intubation. We excluded patients with prior history of myocardial infarction. We performed propensity matching for demographics and nine pre-existing conditions associated with mortality. Results: There were 15,514 patients in the succinylcholine group and 14,675 patients in the rocuronium group for a total of 30,189 adults prior to propensity matching. The final cohort included 26,884 patients evenly divided between groups after propensity matching. Patients given succinylcholine were associated with a significantly lower risk of mortality (30.1% vs 33.4%, risk ratio [RR] 0.901, 95% CI, 0.869-0.933, P < .001, absolute risk reduction of 3.3%) and myocardial infarction (10.5% vs 11.9%, RR 0.888, 95% CI, 0.828-0.953, P = .001, absolute risk reduction of 1.4%) within 60 days after rapid sequence intubation. Trends were similar before propensity matching. Conclusion: Succinylcholine administration was associated with reduced mortality compared to rocuronium. These findings suggest succinylcholine may be a safer paralytic agent for rapid sequence intubation when no contraindications are identified.

Evaluation of neuromuscular blocker use in myasthenia gravis patients undergoing rapid sequence intubation.

Target controlled infusions for rapid sequence induction: anational survey of practice.

Patients with acute upper gastrointestinal hemorrhage (UGIH) often present with airway contamination due to hematemesis and gastric reflux. Conventional endotracheal intubation (ETI) in the supine position faces challenges such as limited visualization and high aspiration risk. While securing the airway and controlling bleeding are both critical during resuscitation, simultaneous achievement of these goals remains technically difficult. A 56-year-old woman with esophageal variceal rupture presented with hemorrhagic shock. After left-lateral positioning and rapid-sequence induction, a cuffed endotracheal tube pre-loaded with a J-tipped guidewire was advanced through the right channel of a bite block into the oropharynx. Under continuous direct visualization provided by a standard diagnostic gastroscope, the tube was steered into the glottis on the first attempt. The scope was then advanced through the tube into the esophagus, permitting immediate endoscopic band ligation of all bleeding varices. The entire process from securing the airway to endoscopic access was completed without apparent delay, with no clinically evident aspiration and with maintained hemodynamic stability. This case demonstrates the technical feasibility of standard gastroscope‑guided intubation in the lateral decubitus position for airway management in massive upper gastrointestinal (GI) bleeding with hypovolemic shock. The procedure enabled rapid airway control without repositioning‑induced hemodynamic instability, allowed seamless transition to endoscopic hemostasis, and was not associated with visible aspiration or mucosal injury. Considering the limitations of a single case, the approach may reduce risk and appears feasible in this instance. These findings are descriptive and not generalizable. The technique may be considered a potential alternative in selected high‑risk "bloody airway" scenarios when advanced bronchoscopic equipment is unavailable. Further validation in larger studies is needed.

This study validated the HEAVEN criteria as a tool for predicting difficult airways during emergency rapid sequence intubation (RSI) in a large air medical cohort of 2,419 patients. Each HEAVEN criterion was independently associated with lower first-attempt success, and overall intubation success decreased as more criteria were present (from 94% with none to 43% with five or more). The criteria demonstrated high negative predictive value, supporting their usefulness for identifying difficult airways in emergency RSI settings.

Effectiveness of mixed reality-based intubation nursing simulation: A randomized controlled trial.

For many years, controlled rapid sequence induction (cRSI) has been recommended in children at risk of aspiration to reduce the risk of hypoxia; however, no fixed age limit has been defined for the transition to classical RSI. This study examines the current practices of RSI in children as well as controversies regarding existing approvals, recommendations and clinical guidelines. An anonymous online survey was carried out among the members of the Scientific Working Group on Pedíatric Anesthesia (WAKKA) of the German Society of Anesthesiology and Intensive Care Medicine (DGAI). Atotal of 244 questionnaires could be evaluated. Of the respondents 218 were specialists and 191 respondents performed pediatric anesthesia at least once aweek. For 73.4%, there was no fixed age limit for cRSI. Despite off-label-use propofol is the most frequently used hypnotic agent also in the group of premature and newborn infants and rocuronium was the most used muscle relaxant in all age groups. Pressure-controlled ventilation until intubation is performed by 80% of the respondents. The standard use of avideo laryngoscope for cRSI is confirmed by 34.8% of the respondents and relaxometry is used routinely by 59.8%. Controversial practices include the use of propofol in premature and newborn infants and the inconsistent use of video laryngoscopy, relaxometry, neuromuscular blocking agents, neuromuscular monitoring and mechanical pressure-controlled intermediate ventilation. The transition to classical RSI is based on individual patient circumstances regarding the risk of hypoxia. No fixed age limit could be identified.

Airway management is an important skill for clinicians who care for adults who are acutely ill. Tracheal intubation can be life saving, but also carries a high rate of complications. Numerous tools are available to assess the difficulty of bag-valve-mask ventilation, intubation, and cricothyroidotomy; however, these tools currently have limited predictive value. Preparation, preoxygenation with non-invasive positive pressure ventilation, and physiological optimization are therefore essential steps to all airways. Drugs for induction and paralysis should be tailored to the patient. If rapid sequence intubation is performed, video laryngoscopy is preferred over direct laryngoscopy because it increases the likelihood of first pass success. Confirmation should include capnography or point-of-care ultrasound. Clinicians should ensure adequate analgesia and sedation to avoid patients experiencing awareness with paralysis, but this must be balanced with avoiding oversedation. This review summarizes the current data and provides an evidence based approach to airway management in the acute care setting.

Ketamine Versus Etomidate in Rapid Sequence Intubation: What Difference Would Convince You?: April 2026 Annals of Emergency Medicine Journal Club.

Rapid sequence induction in patients with obesity - never is never right and always is always wrong.

Background Despite established guidelines emphasizing the importance of post-intubation analgesia and sedation in trauma patients, adherence remains suboptimal. The goal of this study was to understand the association between appropriate post-intubation sedation and analgesia infusions received by injured and intubated adult patients in New Brunswick (NB) before and after the introduction of a provincial guideline and educational intervention. Methods We conducted a retrospective cohort study using data from the NB Trauma Registry, analyzing 202 ED-intubated adult trauma patients (mean age, 46 years; 78% male) treated at Level 1-3 and 5 centers. The primary outcome was the proportion of patients receiving both analgesia and sedation prior to the creation and implementation of the Trauma NB consensus statement, Adult Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients, and the subsequent educational intervention. We chose 2017 as the pre-intervention period, 2019 as the post-intervention period, and 2021 as the follow-up period. Secondary outcomes included whether no infusions were given, only analgesia was given, or only sedation was given. Results A total of 202 intubated adult trauma patients were included: 62 pre-intervention (2017), 72 post-intervention (2019), and 68 at follow-up (2021). The cohort had a mean age of 46 years and was predominantly male (78%). Motor vehicle collisions (51.5%) and falls (20.3%) were the most common mechanisms of injury, with a mean pre-intubation Glasgow Coma Scale score of 9. The proportion of patients receiving both analgesia and sedation increased significantly from 22.6% (95% CI, 13.8-34.5%) in 2017 to 61.1% (49.6-71.6%) in 2019 and 73.5% (61.9-82.6%) in 2021, representing a 3.3-fold improvement (p < 0.05). Omission of both therapies declined from 41.9% (30.4-54.3%) pre-intervention to 16.7% (9.6-27.1%) post-intervention and 8.8% (3.8-18.3%) at follow-up (p < 0.05). Sedation-only use decreased from 30.7% (20.5-43.0%) to 13.9% (7.5-23.9%) and 8.8% (3.8-18.3%), while analgesia-only use remained uncommon (4.8-8.8%). Conclusions Province-wide guideline implementation and educational intervention were associated with improved adherence to evidence-based post-intubation pharmacotherapy, with sustained effects at three-year follow-up. These findings suggest that standardized protocols and educational interventions may be effective tools for improving the quality of trauma airway management.

Difficult and failed tracheal intubation during cesarean delivery under general anesthesia represents a significant patient safety concern in obstetric anesthesia. Physiological changes during pregnancy increase airway management challenges and may lead to serious maternal and neonatal complications. Data from resource-limited settings remains limited. Objective: To determine the incidence of difficult and failed tracheal intubation during cesarean delivery under general anesthesia and to evaluate airway characteristics and management strategies. Methods: This retrospective observational study was conducted at Hameed Latif Hospital, Lahore, Pakistan. Medical records of women who underwent cesarean delivery under general anesthesia between January 2014 and December 2016 were reviewed. Out of 5,637 cesarean sections performed during the study period, 4,330 cases with complete anesthesia records were included. Data regarding demographic characteristics, comorbidities, airway assessment parameters, laryngoscopic view, and airway management techniques were extracted. Difficult intubation was defined as intubation requiring more than one attempt or additional airway adjuncts, while failed intubation referred to the inability to secure the airway during rapid sequence induction. Data were analyzed using SPSS version 22 and presented as mean ± standard deviation or frequencies and percentages. Results: A total of 4,330 patients were analyzed. The mean maternal age was 28.98 ± 4.52 years, and the mean BMI was 30.12 ± 5.16 kg/m². Most participants were classified as ASA II (98.5%), and 76.6% underwent elective cesarean section. Mallampati grade II was the most common airway classification (41.9%), and Cormack–Lehane grade I laryngoscopic view was observed in 68.2% of patients. Difficult or failed tracheal intubation occurred in 30 cases (0.69%). Difficult intubation was observed in 29 patients (0.67%), whereas failed intubation occurred in one patient (0.02%). Among difficult airway cases, airway management was successfully achieved using a stylet with BURP maneuver (17 cases), gum elastic bougie (6 cases), a second attempt by a senior consultant (4 cases), and fiberoptic bronchoscopy (2 cases). Conclusion: The incidence of difficult and failed tracheal intubation during cesarean delivery under general anesthesia was low in this cohort. Careful preoperative airway assessment, availability of airway adjuncts, and experienced anesthesiology supervision appear to contribute to successful airway management and improved maternal safety.

Effect of cricoid pressure on tracheal intubation time during C-MAC video laryngoscopy: A Randomized Controlled Trial.

It has been recommended that prehospital rapid sequence intubation (PH-RSI) be performed in locations that provide 360-degree access to the patient. We aimed to examine the success and complication rate of PH-RSI by location of intubation as well as the effect on scene time. We conducted a single-centre, retrospective cohort study of patients with attempted PH-RSI over a 96-month period. Locations compared were intubation within the road ambulance, outside the vehicle on a stretcher, on the ground and in other locations. The primary outcome was the occurrence of major intubation complications by location. Secondary outcomes were first-pass success, time to intubation from patient contact and total scene time. Modified Poisson with robust SE variance and quantile regressions was used to adjust for confounding variables. Of 413 patients, major intubation complications occurred in 60 (14.5%, 95% CI 11.3% to 18.3%) patients. Patients intubated on the ground were twice as likely to have complications than patients intubated on a stretcher outside the vehicle (p=0.023) in the unadjusted analysis. First-pass success intubations occurred in 400 (96.9%, 95% CI 94.7% to 98.3%). Adjusted time from contact to intubation was not different (p=0.864) but total scene time was significantly shorter for patients intubated inside an ambulance compared with outside on a stretcher (median difference -4.0 min, 95% CI -6.5 to 1.5; p=0.002). Intubating selected patients within an ambulance had similar complication rates to intubation on a stretcher outside the vehicle but was associated with a small reduction in on-scene time.

The optimal hypnotic agent for rapid sequence intubation (RSI) in critically ill patients remains uncertain. We evaluated whether Ketamine is a better alternative than propofol. In this investigator-initiated, randomized, controlled, open-label trial conducted in two mixed ICU, adults (≥ 18years) requiring RSI were assigned 1:1 to Ketamine or propofol. The primary outcome was the lowest mean arterial pressure (MAP) within the first 10min after induction, analyzed with a linear regression model adjusted for age, baseline MAP, and total vasopressor dose within 10min. From October 2021 to October 2023, 207 patients were randomized and 175 were included in the modified intention-to-treat analysis. The lowest MAP within 10min was 66 (55-79) mmHg with Ketamine and 60 (48-72) mmHg with propofol (mean difference, 6.0 [95% CI - 0.0 to 11.9]; p = 0.050). The average MAP difference over the first hour was 1.67 (95% CI - 1.98 to 5.31). Cardiovascular collapse occurred in 20/91(22%) Ketamine-treated patients and 28/84 (33%) receiving propofol, mainly due to an increase in the vasopressor dose within 2min. Day-7 mortality was 33% with Ketamine and 23.8% with propofol (OR 1.38; 95% CI 0.86-2.24). Hospital mortality was 60.4% and 50.0%, respectively (OR 1.21; 95% CI 0.92-1.58). Among critically ill patients undergoing RSI, Ketamine resulted in a less pronounced decrease in MAP in the first 10min compared with propofol, but the difference was not clinically meaningful or sustained. These findings challenge sedative selection based solely on perceived risk of hypotension and highlight the need for larger trials to determine the optimal induction agent. NCT05092152-initial release 10.13.2021.

Evaluating the Role of Apneic Oxygenation in Reducing Hypoxemia during Rapid Sequence Intubation in Critically Ill Patient