title: The importance of first pass success when performing orotracheal intubation in the emergency department.
abstract: OBJECTIVE
  The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations.
  
  
  METHODS
  This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders.
  
  
  RESULTS
  Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63).
  
  
  CONCLUSIONS
  When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.
authors.affiliation: Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA. sakles@aemrc.arizona.edu
authors.forename: John C
authors.initials: JC
authors.lastname: Sakles
authors.forename: Stephen
authors.initials: S
authors.lastname: Chiu
authors.forename: Jarrod
authors.initials: J
authors.lastname: Mosier
authors.forename: Corrine
authors.initials: C
authors.lastname: Walker
authors.forename: Uwe
authors.initials: U
authors.lastname: Stolz
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D015331:Cohort Studies; D016001:Confidence Intervals; D004635:Emergency Medicine / Q000592:standards / Q000639:trends; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D058996:Quality Improvement; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors