The Hallway Consult — Issue #1: Airway & Resuscitation

Video Laryngoscopy Wins. Stop Debating.

The DEVICE trial settled what every airway course has been arguing about for a decade. This multicenter RCT randomized 1,417 adults requiring intubation in emergency departments and ICUs across 17 U.S. sites to either video laryngoscopy (VL) or direct laryngoscopy (DL) as the first-attempt device.

First-attempt success with VL was 85.1% vs. 70.8% with DL — a 14-percentage-point improvement that's hard to ignore. The benefit held across all operator experience levels, not just attendings. The “you should learn DL first, always use DL as a fallback” crowd took a hit here: VL improved success whether the intubator was a resident or an experienced attending.

Caveats worth knowing: the trial was unblinded (obviously), and choice of blade varied. The multicenter design across academic EDs may not generalize to community settings where VL availability varies. This also doesn't mean DL skills are 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 ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;389(5):418-429.

NIV Pre-Oxygenation Before Emergency Intubation: This Is the Move

The PREOXI trial (2024, NEJM) asked a question that matters every time you're about to push the succinylcholine: does noninvasive ventilation (NIV/BiPAP) pre-oxygenation before emergency intubation reduce hypoxemia compared to a standard oxygen mask? This randomized trial enrolled approximately 1,301 critically ill adults across 24 U.S. EDs and ICUs.

The answer was yes, clearly. NIV pre-oxygenation (BiPAP, FiO2 100%, expiratory pressure ≥5 cm H₂O, inspiratory pressure ≥10 cm H₂O) reduced the incidence of hypoxemia (SpO2 <85%) during intubation to 9.1% vs. 18.5% in the mask group — roughly halving the risk of a dangerous desaturation event. Severe hypoxemia was also less common.

Why does NIV work here? The positive pressure pre-loads the lungs with oxygen, recruits atelectatic alveoli, and effectively extends the safe apnea time before SpO2 drops during RSI. This is meaningful for the patients most at risk: those who are already hypoxic, obese, or have limited reserve. The mask group in PREOXI represents standard care — NIV is the upgrade.

Important clarification: this trial studied NIV/BiPAP, not high-flow nasal cannula (HFNC). These are different devices and different mechanisms. HFNC remains useful for apneic oxygenation during the intubation attempt itself, but PREOXI's pre-oxygenation benefit was achieved with NIV.

Bottom line: Use NIV/BiPAP for pre-oxygenation before emergency intubation in patients at risk for desaturation — it roughly halves hypoxemia events compared to a standard oxygen mask.

Gibbs KW, Semler MW, Driver BE, et al. Oxygen Delivery during Endotracheal Intubation in Critically Ill Adults. N Engl J Med. 2024;391(3):224-234.

Refractory VF: Double Shock or Vector Change — Pick One, Just Stop Doing Nothing

The DOSE VF trial (NEJM, 2022) is one of the most practice-relevant resuscitation papers of the decade. This cluster RCT randomized OHCA patients with refractory VF (≥3 failed defibrillation attempts) to standard defibrillation, vector change defibrillation (VC-D), or double sequential external defibrillation (DSED). The trial enrolled 405 patients across six Ontario paramedic services — it was stopped early amid paramedic staffing shortages during the COVID era before reaching its planned enrollment of 930.

Results: survival to hospital discharge was 13.3% in the standard group, 21.7% in the VC-D group, and 30.4% in the DSED group. That's a near-doubling of survival for DSED vs. standard shocks. Favorable neurological outcome tracked similarly. Both VC-D and DSED were superior to standard defibrillation for VF termination and ROSC.

Refractory VF is common — and may account for up to half of VF cardiac arrests — and it's usually a death sentence with standard algorithms. This trial says it doesn't have to be. The mechanism isn't fully understood: current thinking involves simultaneous depolarization of a larger myocardial mass, interrupting more fibrillation wavefronts at once. Whatever the mechanism, it works. The main operational hurdle is having two defibrillators positioned correctly, which is achievable with advance planning.

Bottom line: When VF doesn't convert after 3 shocks, switch pad positions (vector change) or apply double sequential external defibrillation — both dramatically improve survival compared to repeating standard shocks.

Cheskes S, Dorian P, Feldman M, et al. Double Sequential External Defibrillation for Refractory Ventricular Fibrillation. N Engl J Med. 2022;387(21):1947-1956.

If you haven't internalized this yet, now's the time.

SGA vs. ETI in OHCA: AIRWAYS-2

Published in JAMA in 2018, the AIRWAYS-2 trial randomized 9,103 adults with OHCA to either a supraglottic airway device (i-gel) or tracheal intubation as the initial airway strategy by paramedics. This is the largest randomized airway trial in cardiac arrest ever conducted.

The result? No statistically significant difference in neurological outcome at 30 days (favorable outcome 6.4% SGA vs. 6.8% ETI, adjusted OR 0.92, 95% CI 0.77-1.09). The trial also found better fluid regurgitation protection with SGA and comparable ventilation quality, with the SGA being faster to place.

This doesn't mean ETI is wrong. It means that getting hung up on tube-at-all-costs in a cardiac arrest is probably not the best use of your team's cognitive load and interruption-to-compressions ratio. The message is: use what your system does well. High-quality CPR still matters more than the airway device choice. If your system trains more heavily in SGA, outcomes are the same. Stop interrupting compressions chasing a perfect tube.

Bottom line: Supraglottic airway devices are equivalent to tracheal intubation for OHCA outcomes — choose the device that minimizes CPR interruption and gets your team working smoothly together.

Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. JAMA. 2018;320(8):779-791.

Next week:

• Sepsis fluid resuscitation: Are we still drowning our patients? The CLOVERS and PLUS trials weigh in
• Antibiotic timing in sepsis: What the data actually says about the 1-hour door-to-antibiotic rule
• Steroids in septic shock: Still controversial, but getting less so

The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.

The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.