Laryngoscopic views during rapid sequence intubation in the emergency department

Our objective was to document and compare the views obtained at laryngoscopy during emergency department (ED) rapid sequence intubation (RSI) by anesthetists and emergency physicians of varying seniority and experience.

Data were prospectively collected on every intubation attempt in 7 urban Scottish EDs for 2 calendar years, commencing Jan. 11, 1999. Data included patient's age, gender, grade and specialty of intubator, laryngoscopic grade, and number of intubation attempts. Quality of laryngoscopic visualization was graded using the Cormack-Lehane scale, with grades I and II considered good visualization. A descriptive analysis was performed, and key statistical comparisons made.

During the study period, 735 patients underwent RSI, and grade of intubation was documented in 672 cases (91%). In total, 68.2%, 23.4%, 6.1% and 2.4% of the intubations were classified as Cormack-Lehane grade I, II, III and IV respectively. Overall, anesthetists and anesthesia trainees achieved good laryngoscopic visualization in 94.0% of cases (95% confidence interval [CI], 90.8%-96.4%) and emergency physicians and emergency medicine trainees did so in 89.2% of cases (95% CI, 85.5%-92.3%; p = 0.027). Specialist registrars and senior house officers in anesthesia were more likely to obtain good visualization than their emergency medicine counterparts (p = 0.034 and 0.035 respectively). Consultants in emergency medicine were more likely to obtain good views than their anesthesia counterparts, but this difference was not statistically significant.

Anesthetic trainees obtain better laryngoscopic views than emergency medicine trainees, but these differences disappear with increasing emergency physician seniority, suggesting a training and experience effect. Emergency medicine trainees may benefit from additional focus on laryngoscopic visualization techniques early in their training period.