🩺 THIS WEEK IN EM
Video Laryngoscopy Wins. Stop Debating.
The DEVICE trial finally settled what every airway course has been arguing about for a decade. This multicenter RCT randomized 1,417 adults requiring intubation across 17 U.S. EDs and ICUs to video laryngoscopy (VL) vs. direct laryngoscopy (DL) as the first-attempt device.
First-attempt success: 85.1% VL vs. 70.8% DL. The benefit held across all operator experience levels — residents and attendings alike. The "always use DL as your backup" crowd took a real hit here.
Caveats: unblinded trial, blade choice varied, academic ED setting may not generalize everywhere. DL skills aren't dead — VL is a tool, not a replacement for knowing what you're doing.
Bottom line: Video laryngoscopy should be your default first-attempt device for emergency intubation in adults. Make it your go-to, not your backup.
Prekker et al. N Engl J Med. 2023;389(5):418-429.
High-Flow Nasal Oxygen During Pre-Oxygenation: Actually Worth the Setup Time
The PREOXI trial (NEJM, 2024) asked whether HFNC pre-oxygenation before emergency intubation reduces hypoxemia vs. standard facemask. Over 1,300 critically ill adults, 24 U.S. EDs and ICUs.
HFNC at 60 L/min cut hypoxemia (SpO2 <85%) roughly in half: 9% vs. 19%. Severe hypoxemia (<80%) was also less common. The mechanism is simple physics — HFNC generates PEEP, washes out dead space, and provides passive apneic oxygenation during RSI. No magic required.
Bottom line: Set up HFNC before every emergency intubation you can. Minimal setup time, half the desaturation risk.
Gibbs et al. N Engl J Med. 2024;391(3):224-234.
Refractory VF: Double Shock or Vector Change — Pick One, Just Stop Doing Nothing
DOSE VF (NEJM, 2022): cluster RCT, 405 OHCA patients with refractory VF (≥3 failed shocks), randomized to standard defibrillation, vector change (VC-D), or double sequential external defibrillation (DSED).
Survival to discharge: 13.3% standard vs. 21.7% VC-D vs. 30.4% DSED. Near-doubling of survival for DSED. Refractory VF affects ~25% of all VF arrests and is usually fatal with standard algorithms. This trial says it doesn't have to be. The main hurdle is having two defibrillators positioned correctly — achievable with planning.
Bottom line: After 3 failed shocks, switch pad positions or apply double sequential defibrillation. Both dramatically improve survival vs. repeating standard shocks.
Cheskes et al. N Engl J Med. 2022;387(21):1947-1956.
📚 STILL CHANGING PRACTICE
SGA vs. ETI in OHCA: AIRWAYS-2
JAMA, 2018. The largest randomized airway trial in cardiac arrest ever: 9,103 adults, supraglottic airway (i-gel) vs. tracheal intubation by paramedics.
Result: no difference in neurological outcome at 30 days (6.4% vs. 6.8%). SGA was faster to place and had better protection against regurgitation.
The message isn't that ETI is wrong — it's that getting tunnel-visioned on the tube while interrupting compressions is probably costing lives. High-quality CPR matters more than the airway device. Use what your system does well.
Bottom line: SGAs are equivalent to ETI for OHCA outcomes. Choose the device that minimizes CPR interruption and keeps your team moving.
Benger et al. JAMA. 2018;320(8):779-791.
Next week: Are we still drowning our sepsis patients? CLOVERS and PLUS trials, antibiotic timing, and steroids in septic shock.
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.