Video versus direct laryngoscopy for tracheal intubation in trauma: A secondary analysis of the DEVICE trial

Endotracheal intubation is the most common airway intervention in the deployed combat setting, including far-forward Role 1 battalion aid stations. Intubation in this setting is often performed by novice intubators, adding to the complexity of this time-sensitive intervention. Two types of laryngoscopes are commonly used to perform tracheal intubation: a direct laryngoscope (DL) and a video laryngoscope (VL). Data to inform deployed clinical practice guidelines for the best device are currently lacking.

We performed a preplanned secondary analysis of the DEVICE trial-a multicenter, pragmatic, randomized, parallel-group trial comparing the use of a VL to a DL for emergency intubation of critically ill adults. Only patients intubated in the setting of traumatic injury were included in this secondary analysis. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of a severe complication during intubation. The main analysis for both the primary and secondary outcomes was an unadjusted, intention-to-treat comparison of the outcome between groups using a χ 2 test.

Of the 1,417 patients in the DEVICE trial, 338 patients (24%) were intubated in the setting of a traumatic injury. Successful intubation on the first attempt occurred in 151 of 171 (88%) of patients randomized to a VL as compared to 114 of 167 (68%) of patients randomized to a DL (absolute risk difference 20%, 95% CI, 11%-29%). The incidence of severe complications during intubation and in-hospital outcomes did not significantly differ between groups.

Among adults undergoing tracheal intubation in the setting of trauma, use of a VL significantly increased the incidence of successful intubation on the first attempt. Future guidelines, including the Joint Trauma System guidelines, should encourage VL use as the first-line approach for emergency intubation in trauma, especially for operators with limited experience. ( J Trauma Acute Care Surg . 2026;101: 359-365. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).