Objectives Endotracheal intubation of trauma patients is a vital and high‐risk procedure in the emergency department (ED). The hypothesis was that implementation of a standardized, preprocedural checklist would improve the safety of this procedure. Methods A preprocedural intubation checklist was developed and then implemented in a prospective pre‐/postinterventional study in an academic trauma center ED. The proportions of trauma patients older than 16 years who experienced intubation‐related complications during the 6 months before checklist implementation and 6 months after implementation were compared. Intubation‐related complications included oxygen desaturation, emesis, esophageal intubation, hypotension, and cardiac arrest. Additional outcomes included time from paralysis to intubation and adherence to safety process measures. Results During the study, 141 trauma patients were intubated, including 76 in the prechecklist period and 65 in the postchecklist period. A lower proportion of patients experienced intubation‐related complications in the postchecklist period (1.5%) than the prechecklist period (9.2%), representing a 7.7% (95% confidence interval = 0.5% to 14.8%) absolute risk reduction. Paralysis‐to‐intubation time was also lower in the postchecklist period (median = 82 seconds, interquartile range [IQR] = 68 to 101 seconds) compared to the prechecklist period (median = 94 seconds, IQR = 78 to 115 seconds; p = 0.02). Adherence to safety process measures also improved, with all safety measures performed in 69.2% in the postchecklist period compared to 17.1% before the checklist (p < 0.01). Conclusions Implementation of a preintubation checklist for ED intubation of trauma patients was associated with a reduction in intubation‐related complications, decreased paralysis‐to‐intubation time, and improved adherence to recognized safety measures.

Study objective Induction doses of etomidate during rapid sequence intubation (RSI) cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for RSI induction. Among adult trauma patients emergently intubated, we compared clinical outcomes among those induced with etomidate and ketamine. Methods The study entailed a retrospective evaluation of a four-year (January 2011–December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing RSI in the ED of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included intensive care unit (ICU)-free days and ventilator-free days (VFD) evaluated with multivariable ordered logistic regression using the same covariates. Results The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared to 17.3% among those induced with etomidate (aOR: 1.41; 95% CI: 0.92, 2.16). Patients induced with ketamine had similar ICU-free-days (aOR: 0.80; 95% CI: 0.63, 1.00) and VFDs (aOR: 0.96; 95% CI: 0.76, 1.20) as compared to patients induced with etomidate. Conclusion In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard RSI induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

IMPORTANCEFor critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.OBJECTIVE To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt. DESIGN, SETTING, AND PARTICIPANTS The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021. INTERVENTIONS Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). MAIN OUTCOMES AND MEASURESThe primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%. RESULTS Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.CONCLUSIONS AND RELEVANCE Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

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