Written by Aaron Lacy
Similar to prior research on the topic, prehospital endotracheal intubation (ETI) is more successful with both sedative and paralytic than with no medications or sedative alone.
Friends don’t let friends intubate without drugs
Across the United States, paramedics perform hundreds of thousands of intubations each year. Success on the first attempt is imperative to prevent complications and facilitate timely patient transport and resuscitation.
Current expert recommendations for prehospital airway management include the use of both sedative and paralytic (drug-assisted intubation; DAI), although this recommendation was conditional and based on very low certainty of evidence. They comment that further evidence to bolster the recommendation of prehospital DAI was needed.
This observational study of a large cohort of Texas-based EMS agencies looked at 12,713 patients who underwent ETI in the prehospital setting (excluding those in cardiac arrest) and found an overall first attempt success rate of 75.1%. Rapid sequence intubation (sedative + paralytic, aka RSI) was more likely to be successful on the first attempt compared to no medication (OR 2.23, 95%CI 2.00 to 2.50) or sedative-only intubation (OR 2.14, 95%CI 1.88-2.43). Paralytic-only intubation was essentially as good as RSI compared to no medication (OR 2.11, 95%CI 1.38-3.24).
How will this change my practice?
What is the point of allowing prehospital personnel to perform ETI if you aren’t going to let them optimize their chance for success? It seems silly to allow paramedics to intubate patients, but then restrict the drugs to do it properly; in that case, just ask for SGA placement instead. ETI is a high-risk procedure. Assuming appropriate quality assurance and oversight, if you are going to let prehospital providers intubate, let them have all the tools—including the drugs to do it right.
Source
The Association Between Out-of-Hospital Drug-Assisted Airway Management Approach and Intubation First-Pass Success. Ann Emerg Med. 2025 Nov;86(5):521-530. doi: 10.1016/j.annemergmed.2025.04.034. Epub 2025 Jun 4. PMID: 40464718.
