Rapid Sequence Intubation Boosts First-Pass Success

TOPLINE:

In a US study of patients without cardiac arrest who required prehospital intubation, rapid sequence intubation (RSI), involving the use of a sedative and paralytic, was associated with increased odds of first-pass success compared with intubation without medication.

METHODOLOGY:

• Researchers performed a retrospective observational analysis using the 2022 Emergency Services Organization Data Collaborative dataset containing records from emergency medical services (EMS) agencies in the US.
• The analysis included 12,713 patients (median age, 60 years; 58.4% men; 24.2% traumatic cases) who underwent at least one intubation attempt during a 911 response. Patients in cardiac arrest were excluded.
• The researchers categorized drug-assisted airway management approaches on the basis of medications administered before the initial endotracheal intubation attempt: RSI (including both a sedative and a paralytic; 51.2%), sedative-only intubation (17.9%), paralytic-only intubation (1.3%), and no-medication intubation (29.6%).
• The primary outcome was first-pass intubation success.

TAKEAWAY:

• The overall first-pass success rate was 75.1%.
• The adjusted odds of achieving first-pass success were higher with RSI (adjusted odds ratio [aOR], 2.23; 95% CI, 2.00-2.50) and paralytic-only intubation (aOR, 2.11; 95% CI, 1.38-3.24) than with no-medication intubation.
• RSI showed increased odds of first-pass success compared with sedation-only intubation (aOR, 2.14; 95% CI, 1.88-2.43).
• Sedation-only intubation showed success rates similar to those of no-medication intubation.

IN PRACTICE:

“In this analysis of a large national EMS dataset of noncardiac arrest patients undergoing endotracheal intubation, rapid sequence intubation was associated with twofold higher odds of first-pass success compared with sedation-only or no-medication approaches,” the authors wrote.

SOURCE:

The study was led by Jeffrey L. Jarvis, MD, MS, EMT-P, Burnett College of Medicine, Texas Christian University, Fort Worth, Texas. It was published online on June 04, 2025, in the Annals of Emergency Medicine.

LIMITATIONS:

The study focused solely on the association between drug combination and first-pass success, without evaluating causation, procedure indication appropriateness, adverse events, or clinical outcomes. EMS treatment protocols were not uniform across agencies, and the dataset lacked information on clinician experience with intubation. Variability in EMS protocols and clinician experience, potential data entry or documentation errors (including reliance on self-reported data), and a small sample size for paralytic-only intubations were additional limitations.

DISCLOSURES:

Funding information was not provided for the study. One author reported serving as an unpaid board member for the National Emergency Medical Service Quality Alliance, the National Association of Emergency Medical Technicians, and the Prehospital Guidelines Consortium, unrelated to this study. He also reported receiving unrestricted honoraria for speaking on various topics at EMS-related conferences.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.