Success Rates and Adverse Events of Advanced Airway Management Techniques in the Emergency Department: A Prospective Observational Study

Background: Advanced airway management is a core component of the emergency response.Different intubation techniques may differ in their likelihood of success on the first attempt and in the incidence of associated adverse events.Analyzing routine emergency practice can identify opportunities to improve airway safety and procedural performance.Objective: This study aimed to determine the first-pass success and complications of different advanced airway-management methods and to describe the indications for, and medications used in, emergency airway management.Methods: This prospective observational study enrolled adult patients requiring advanced airway management during an emergency department (ED) visit over 12 months (December 2019 to November 2020) at a tertiary care teaching hospital in Kannur, Kerala, India.Of 247 patients assessed, three were excluded because consent could not be obtained, leaving 244 patients.Airway techniques were classified as rapid sequence intubation (RSI), delayed sequence intubation (DSI), crash intubation, and awake intubation.All intubations were performed by emergency physicians with prior experience of more than 100 endotracheal intubations.The primary outcomes were first-pass success and adverse events occurring within 15 minutes of airway management.Proportions are reported with 95% confidence intervals (CIs) calculated by the Wilson score method, and associations were assessed using the Fisher-Freeman-Halton exact test.Results: The mean age of participants was 63.1 ± 9.7 years, and 136 (55.7%) were male.RSI was the most frequently used technique (179/244, 73.4%), followed by crash intubation (38/244, 15.6%), DSI (25/244, 10.2%), and awake intubation (2/244, 0.8%).Overall first-pass success was 91.4% (223/244; 95% CI: 87.2-94.3),and all 244 patients were ultimately intubated within two attempts, with no surgical airway required.First-pass success was high across the cohort, although comparisons between techniques were inconclusive because of markedly unequal subgroup sizes, particularly the very small awake-intubation group.Adverse events occurred in 30 patients (12.3%; 95% CI: 8.7-17.0),comprising 8.9% of RSI, 28.0% of DSI, and 18.4% of crash intubation cases, with none among the two awake-intubation cases (p = 0.031).The most common adverse event was dental trauma.Non-traumatic indications predominated (75.0%), the leading indication being respiratory failure, whereas head injury was the most common traumatic indication.Etomidate was the most frequently used induction agent, and rocuronium was the only neuromuscular blocking agent recorded.Conclusions: Advanced airway management in this ED cohort was associated with a high first-pass success rate and a relatively low rate of adverse events recorded within the 15-minute observation window, with RSI the predominant technique and all intubations performed by experienced operators.The study was designed to estimate the overall first-pass success rate, not to compare techniques: subgroups were markedly unequal, technique was selected on clinical grounds rather than randomly allocated, and pre-intubation physiological severity was not recorded.The apparent differences in first-pass success and adverse events among techniques are therefore inconclusive and are likely to reflect confounding by indication; no inference about the relative effectiveness or safety of individual techniques should be drawn from these data.