Endotracheal intubation (ETI) has long been defined as the “gold standard” for airway management to secure the airway. It is historically the “definitive airway” and, in the setting of cardiac arrest, a successfully placed and confirmed endotracheal tube connected to a well-managed ventilator removes the bulk of airway and breathing concerns from the Basic Life Support (BLS)/ Advanced Cardiovascular Life Support (ACLS) algorithms. For many emergency physicians and paramedics, intubation is a standard and satisfying procedure that not only secures a definitive airway but also patient disposition. For these reasons, we often tend to perform ETI as the default mechanism for cardiac arrest. The question remains as to whether it is always the best intervention for airway management in prehospital cardiac arrest.

ETI has a long list of potential medical complications including esophageal intubation, hypoxia, infectious disease exposure, and aspiration. In the setting of cardiac arrest, the interruption of chest compressions can be a significant detriment. ETI takes time: unzipping all the bags, opening the packages, connecting the syringe, checking the cuff, putting in the stylet, connecting one’s preferred blade to a laryngoscope, hooking up the suction, and, finally, positioning the patient. These are all more complicated when they are being performed by a three-person crew on a 90-foot high mezzanine at the brickyard, as opposed to a beautiful, spacious and well-lit resuscitation bay at the trauma center. One of the authors has been in both scenarios, and, unfortunately at the brickyard, the syringe happened to slip off and we had the pleasure of watching the thing fall through the perforated metal floor into a sandpit directly below. Yes, there was a backup in the bag, but digging it out took even more time.

Experience, Timing Matter

It is widely accepted that frequent experience in performing the complex procedure of ETI is what matters most in ascertaining competency. In a large emergency department, intubation is a frequent enough event to generate confidence. However, paramedic experience for intubation may entail one to eight attempts per year.

In a retrospective analysis from Victoria, Australia, it was demonstrated that paramedic intubation experience was associated with successful tube placement but not with cardiac arrest survival to discharge. This study involving highly trained paramedics demonstrated that previous experience correlated with intubation success, which in turn was correlated with return of spontaneous circulation (ROSC). Notably, the authors observed that first-pass success might be the key element in increasing both ROSC and survival to hospital discharge. The authors consequently suggested that paramedics who lack adequate experience should consider using supraglottic airway (SGA) devices.¹