Listen up, street warriors and transport heroes. After 18 years of stuffing tubes down people’s throats and watching others do the same, I need to have a come-to-Jesus talk with y’all about intubation. Because here’s the uncomfortable truth: sometimes we’re the ones doing the killing.
I know, I know. We all became medics to save lives, not take them. But that shiny endotracheal tube in your bag? It’s not just a lifesaver—it’s a loaded weapon. And if you don’t respect it as such, you’re going to hurt someone. Maybe you already have and just don’t know it yet.
The Brutal Reality: What the Numbers Tell Us
Let me start with some sobering statistics that should make every one of us pause before reaching for that laryngoscope. The most recent evidence from the BARCO study shows that one in three patients undergoing emergency intubation experienced a major peri-intubation adverse event, which was associated with higher 28-day mortality. Read that again. One. In. Three.
The landmark INTUBE study—which looked at nearly 3,000 patients across 29 countries—found that 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%).
And here’s the kicker: Overall 28-day mortality was 30.5% (897 of 2942) of patients, with a mortality of 37.7% (500 of 1327) of patients with a major adverse peri-intubation event and 24.6% (397 of 1615) of patients without events. Meanwhile, a separate meta-analysis found that almost one in three patients intubated outside the OR experience a peri-intubation major adverse event.
Translation? Complications during intubation aren’t just “oops” moments—they’re associated with people dying.
The Dirty Dozen: How Intubation Kills
1. The Hypotensive Nightmare: When Blood Pressure Takes a Dive
Here’s something they don’t teach you enough in medic school: intubation can absolutely crater someone’s blood pressure, and when it does, people die. Heffner et al. studied 336 cases and found 23% (79 patients) experienced post intubation hypotension and these patients had worse in-hospital mortality (33% did not survive).
The mechanism: Your sedation and paralytic drugs cause vasodilation and myocardial depression. Add in the loss of sympathetic tone from positive pressure ventilation, and boom—your patient’s pressure tanks. In someone who’s already sick? That’s a recipe for cardiac arrest.
The fix: Know your patient’s shock index before you intubate. Research shows that a pre-intubation shock index of 0.8 or higher comes with 80% specificity for predicting post-intubation hypotension. If they’re hypotensive going in, they’re going to be worse coming out. Push fluids, have your pressors ready, and seriously consider if this tube is worth potentially killing them.
2. Peri-Intubation Cardiac Arrest (PICA): The Big One
This is the nightmare scenario that should wake you up in cold sweats. The NEAR study examined intubation across multiple emergency departments and found that 157 patients (roughly 1% of the study population) experienced peri-intubation cardiac arrest. Of those 157 patients, 32% (about 50 patients) did not survive.
But here’s the really sobering part: newer evidence shows this rate can be much higher in certain populations. De Jong found a 28-day mortality rate of 73% in patients with PICA, compared to 30.1% in patients emergently intubated without PICA, and that PICA was an independent risk factor for mortality with a hazard ratio of 3.9.
Think 1% sounds low? Think again. That’s 1 in 100 intubations leading to cardiac arrest. In a busy system, that’s multiple arrests per year directly caused by our procedures. The mortality in these groups ranges from 30% to as high as 73%.
The warning signs: The largest predictor of PICA was hypotension (defined as SBP < 100). If they’re hypotensive, you’re playing with fire. A recent meta-analysis confirmed that pre-intubation hypotension has a pooled odds ratio of 4.96 for peri-intubation cardiac arrest.
3. The Preoxygenation Fail: Setting Yourself Up for Disaster
Here’s where most of us screw up before we even touch the laryngoscope. We rush the preoxygenation because we’re in a hurry, or we don’t do it properly, or we convince ourselves that 30 seconds of bagging is “good enough.”
The truth: Recent studies indicate that peri-intubation hypoxemia and absence of preoxygenation are associated with higher mortality and morbidity. Proper preoxygenation is not optional—it’s literally the difference between life and death.
Hypoxemia before intubation, or significant desaturation during intubation, increases the risk of peri-intubation cardiac arrest that occurs in up to one in 25 critically ill patients. One in 25! That’s not rare—that’s Tuesday. A recent meta-analysis found that pre-intubation hypoxemia has a pooled odds ratio of 4.43 for causing peri-intubation cardiac arrest.
Do it right: Use high-flow oxygen, position them properly (head up if possible), and take the time to actually denitrogenate their lungs. Eight breaths with full inspiration/expiration to achieve vital capacity in <60 seconds (requires patient cooperation) or 3-5 minutes of tidal volume breathing with 100% FiO2.
4. The Medication Minefield: When Drugs Kill
Let’s talk about the elephant in the room: we make medication errors. A lot. Evidence suggests errors may occur in up to 12.76% of medication administrations in some prehospital settings. With multiple sources stating that the errors are under-reported, this represents significant potential for patient harm.
In pediatrics, it’s even worse. Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has actually increased.
Common killers:
– Overdosing sedatives in hypotensive patients
– Wrong drug concentrations (especially with push-dose pressors)
– Forgetting to adjust doses for patient weight and condition
– Paralytic without sedation (hello, awareness with paralysis)
– Using contraindicated drugs in specific patient populations
5. Hyperventilation: The Silent Killer
This one’s subtle but deadly, especially in head injuries. Field intubation is a high-stress procedure. Often providers will be highly energized with adrenalin and singularly focused on the task at hand, resuscitation. In these high-stress periods, providers may over-aggressively ventilate the patient with rapid rescue breathing via a resuscitator bag.
In trauma patients, hyperventilation causes vasoconstriction and decreased cerebral perfusion. In cardiac arrest, it impedes venous return. In everyone else, it can cause hypotension and arrhythmias.
The fix:Davis et al. performed several studies examining the rate of hyperventilation and hypocarbia post field intubations in patients with traumatic brain injury and their corresponding effect on mortality. Use waveform capnography, aim for normal ETCO2 (35-45), and resist the urge to bag the hell out of them.
6. The Vomit Factor: Aspiration and Death
Everyone knows aspiration is bad, but let’s quantify it. Meta-analysis evidence shows that the risk of intubation-related complications (aspiration or new infiltrate on post-intubation chest radiograph, hemodynamic instability, and cardiac arrest) was lower with noninvasive ventilation than with other preoxygenation methods during emergency intubation.
The reality: Sick patients vomit. Often. And when they do it during or right after intubation, they die. Consider delayed sequence intubation in awake patients who can protect their airway, and always have suction ready and working.
7. The Esophageal Disaster: When You Miss
The data on tube misplacement is absolutely terrifying. A landmark study by Katz and Falk found that misplaced endotracheal tubes occurred 25% of the time in 108 field intubations. Twenty-five percent! That’s not a rare occurrence—that’s every fourth tube.
More recent studies show rates ranging from 4% to 25%. A prospective study found that 12 of 132 (9%) prehospital intubation attempts involved misplaced tubes—11 esophageal and 1 hypopharyngeal. Among patients arriving with unrecognized esophageal misplacement, only one patient survived to hospital discharge.
Unrecognized esophageal intubation kills. Period. Misplaced endotracheal tubes may be detrimental to patients, and inadequate training or experience in intubation among paramedics has been recognized as a problem that could contribute to mortality.
The non-negotiables:
– Waveform capnography (not just colorimetric)
– Visual confirmation of tube passing through cords
– Bilateral breath sounds
– Chest rise
– When in doubt, take it out
One study suggests that tube misplacements can be eliminated with the systematic use of waveform capnography.
8. The Physiologically Difficult Airway: The Sick Patient Paradox
Here’s the cruel irony of emergency medicine: the patients who need intubation the most are often the ones most likely to die from it. While apneic oxygenation can be helpful in some patients, such as those intubated for neurologic injury or airway protection, it is less likely to prevent desaturation in patients with acute hypoxemic respiratory failure.
These are the patients with:
– Severe hypoxemia
– Shock
– Metabolic acidosis
– Right heart failure
They crash faster, desaturate quicker, and tolerate our medications poorly. They need the most careful approach, not the most aggressive one.
9. The Transport Trap: When Moving Kills
Here’s something specific to our world: intubated patients are fragile, and transport makes everything worse. Ventilator disconnections, equipment failures, and rough roads can turn a successful tube into a dead patient.
Survival tips:
– Secure that tube like your license depends on it (because it does)
– Have backup ventilation ready
– Monitor continuously—SpO2, ETCO2, and vitals
– Smooth driving saves lives
10. The Ego Problem: When Pride Kills
Let’s be honest—sometimes we intubate because we can, not because we should. Despite early support for endotracheal tube insertion, the American Heart Association acknowledges the lack of conclusive evidence demonstrating improved survival resulting from advanced airway insertion for adult victims of cardiac arrest.
The hard truth:Sometimes a supraglottic airway is safer. Sometimes CPAP is better. Sometimes basic airway management wins. Despite a lack of proven improvement in outcomes, multiple studies and editorials question the utility of prehospital intubation and show concern for a trend of worse outcomes from field intubation versus basic airway management by EMS.
11. The Training Deficit: When Inexperience Kills
When compared to in-hospital intubation, higher failure and complication rates have brought the practice of field intubation into question. Why? Because emergency intubation is hard, and many of us don’t do it enough to stay proficient.
South African data shows complications including hemodynamic instability (11.6%), tension pneumothorax (3.5%), difficult intubation (2.3%), low ETCO2 (2.3%), high ETCO2 (1.2%), and bronchospasm (1.2%). Four of these patients were hypotensive (4.7%) and 2 hypoxic (2.3%) at handover.
The solution:Train more. Simulate more. Know your limitations and have backup plans.
12. The Time Trap: When Haste Makes Death
We work in a time-pressured environment, but rushing kills. With chest compressions, medication administration, and electrical therapy potentially needed simultaneously during field intubation to successfully resuscitate a patient, it’s challenging to manage it all with the typical two-person EMS crew.
Taking an extra minute to properly preoxygenate, position, and prepare often means the difference between success and disaster.
The Resuscitation Paradox: When NOT Resuscitating Kills
Here’s something that should be obvious but apparently isn’t: if your patient is dying, fix the dying BEFORE you intubate. I can’t tell you how many times I’ve seen providers focus on the tube while the patient bleeds out, goes into shock, or arrests.
The rule:ABCs still matter, but think of them as:
– Airway (only if immediately threatened)
– Breathing (oxygenate and ventilate)
– Circulation (fix the shock FIRST)
If they’re hypotensive, give fluids or pressors before you give paralytics. If they’re hypoxemic, optimize their oxygenation before you take away their respiratory drive. If they’re acidotic, consider if intubation is going to help or hurt.
The Bottom Line: Respect the Tube
Intubation is not a benign procedure. It’s a high-risk intervention that can save lives or take them. Multiple international studies from 29 countries show that major adverse peri-intubation events—particularly cardiovascular instability—are observed frequently during emergency intubation.
Every time you reach for that laryngoscope, ask yourself:
– Does this patient NEED to be intubated right now?
– Are they stable enough to tolerate it?
– Have I optimized their condition first?
– Do I have backup plans if this goes sideways?
– Am I doing this for the right reasons?
A Humbling Confession
I’ve been doing this for almost two decades, and I’ve made every mistake I’ve written about here. I’ve pushed too much sedation, hyperventilated patients, and missed esophageal tubes. I’ve intubated people who probably didn’t need it and failed to intubate people who did.
The difference between an experienced provider and a dangerous one isn’t that we don’t make mistakes—it’s that we learn from them, acknowledge them, and change our practice accordingly.
Remember:Every patient teaches us something. Every complication makes us better—if we let it. And every successful intubation should remind us that we’re privileged to do this job, not entitled to it.
Stay safe out there, keep learning, and never forget that sometimes the best airway management is knowing when NOT to manage the airway.
Real-World Scenarios: When Theory Meets the Street
Here are 12 real scenarios that illustrate how each of these killers plays out in the field. Names and details have been changed, but these are based on actual cases.
Scenario 1: The Hypotensive Nightmare
Maria, 67, fell down her basement stairs. Initial vitals: BP 88/52, HR 118, confused but breathing. The rookie medic sees the head injury and immediately reaches for the intubation kit. “She’s got a significant head injury, we need to protect her airway.” After RSI with etomidate and sux, her pressure drops to 60/30. Despite fluid boluses and pushes of epinephrine, she arrests en route. She never woke up.*
What went wrong:The medic focused on the head injury but missed the obvious signs of shock. Her shock index was 1.3—way above the danger zone of 0.8. She needed blood pressure support BEFORE paralysis, not after.
Scenario 2: Peri-Intubation Cardiac Arrest
James, 45, motorcycle vs. tree. Awake but struggling to breathe, obviously injured chest, BP 95/60. “I can’t… can’t breathe…” The paramedic moves quickly to intubate for respiratory distress. Thirty seconds after pushing the drugs, James goes into PEA arrest. Despite 20 minutes of good CPR, he never gets pulses back.
What went wrong:Classic PICA. James was compensating with increased respiratory effort and sympathetic drive. The moment we took away his ability to breathe and dumped his sympathetic tone with sedation, his marginal physiology collapsed. He needed chest decompression and hemodynamic support first.
Scenario 3: The Preoxygenation Fail
Sarah, 34, severe asthma attack. SpO2 84% on high-flow oxygen. The medic tries to bag her but she’s fighting it. “I don’t have time for this, she’s hypoxic. I’m going to tube her now.” Fifteen seconds into the laryngoscopy attempt, her SpO2 drops to 60%. By the time he gets the tube, she’s in the 40s and bradycardic.*
What went wrong: You can’t preoxygenate someone who’s hypoxic to begin with without addressing the underlying problem first. He should have given bronchodilators, maybe tried CPAP, or at minimum accepted that his safe apnea time was going to be very short and had backup plans ready.
Scenario 4: The Medication Minefield
Tommy, 8 years old, seizure. Mom says he weighs “about 60 pounds, maybe?” The medic calculates the etomidate dose based on 25 kg (55 lbs) and gives 5 mg. Tommy immediately becomes hypotensive and bradycardic. Turns out he actually weighs 35 kg (77 lbs) and was already dehydrated from the prolonged seizure.
What went wrong:Pediatric dosing errors are common and deadly. The medic underestimated the weight and didn’t account for the kid’s volume status. Always use a length-based tape if available, and remember that sick kids are often dehydrated.
Scenario 5: Hyperventilation Death
Mike, 28, head injury from bar fight. Successfully intubated in the field. The EMT driving is excited—his first successful tube. En route, he’s bagging fast and hard. “I want to make sure he gets plenty of oxygen!” ETCO2 is reading 22. Patient arrives with fixed and dilated pupils.
What went wrong:Hyperventilation causes cerebral vasoconstriction. This EMT literally squeezed the blood out of Mike’s injured brain. Normal ETCO2 is 35-45. Below 30 is dangerous in head injuries. The tube was placed successfully, but the ventilation killed him.
Scenario 6: The Vomit Factor
Linda, 72, altered mental status, possible overdose. As soon as the medic gives the etomidate, she vomits—a lot. He tries to suction while continuing the intubation attempt. Gets the tube in, but she’s aspirated significantly. She develops ARDS and dies three days later from pneumonia.
What went wrong: Should have positioned her in Trendelenburg or left lateral, had suction ready and turned on, and considered if she really needed immediate intubation or if she could protect her own airway for transport.
Scenario 7: The Esophageal Disaster
Robert, 55, cardiac arrest. The paramedic gets the tube in quickly—good placement by feel, sees the chest rise, hears breath sounds… or thinks he does. The colorimetric detector shows yellow. But after 10 minutes of CPR, no improvement. At the hospital, they discover the tube is in the esophagus. Robert had been getting air pumped into his stomach for 15 minutes.
What went wrong: In cardiac arrest, colorimetric detectors can be misleading because of poor CO2 production. Breath sounds can be transmitted. Waveform capnography would have immediately shown the problem. “When in doubt, take it out” applies here.
Scenario 8: The Physiologically Difficult Airway
Janet, 67, COPD exacerbation. SpO2 78% despite high-flow oxygen, clearly working hard to breathe. “She’s tired, she needs the tube.” After intubation, her blood pressure crashes and she develops a pneumothorax from the positive pressure ventilation. Despite chest tubes and pressors, she never recovers.
What went wrong:COPD patients with severe exacerbations are physiologically difficult airways. They’re often auto-PEEPing and have right heart strain. Positive pressure ventilation can worsen both. CPAP or BiPAP might have been better, or at least optimizing her condition before intubation.
Scenario 9: The Transport Trap
Kevin, 22, motorcycle accident, successfully intubated at scene. During transport over bumpy rural roads, the tube gets dislodged. The EMT in back doesn’t notice because he’s focused on getting an IV. Patient arrives at hospital hypoxic and bradycardic. Never fully recovers neurologically.
What went wrong:Intubated patients need constant monitoring. Waveform capnography would have alerted them immediately. The tube should have been better secured, and someone should have been watching the monitor continuously.
Scenario 10: The Ego Problem
Frank, 68, cardiac arrest in his driveway. Basic EMTs are doing good CPR with an OPA and BVM. Paramedic arrives: “Step aside, I’ll get this airway.” Takes three attempts to get the tube, interrupting CPR for a total of 4 minutes. Frank never gets pulses back.
What went wrong:The EMTs were doing fine with basic airway management. The paramedic’s need to “upgrade” the airway cost Frank 4 minutes of circulation to his brain. Sometimes the best airway management is knowing when NOT to manage the airway.
Scenario 11: The Training Deficit
Angela, 45, overdose. The new paramedic gets the tube in on the first try—or so he thinks. He’s only done maybe 10 real intubations since graduating. The tube looks like it’s in the right place, but he’s actually in the vallecula. Patient becomes hypoxic and arrests.
What went wrong:Inexperience kills. This medic thought he saw the tube go through the cords, but it was actually sitting above them. He needed more training, more experience, and better supervision. Know your limitations.
Scenario 12: The Time Trap
David, 35, anaphylaxis. Severe stridor, can’t speak, obviously in extremis. The medic spends 5 minutes trying to get an IV for epinephrine while David’s airway swells shut. “I need to get this epi in before I tube him.” By the time he gets IV access, David is in arrest and the airway is too swollen to intubate.
What went wrong:Sometimes you need to address the immediate life threat first. David needed epinephrine NOW—IO, IM, whatever it takes. Or he needed a surgical airway. The medic got tunnel vision and wasted precious time while the patient died.
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