Apneic Oxygenation Including Precipitous Intubations During RSI in the ED

• Lowest oxygen saturation precipitous intubations[ Time Frame: Time between neuromuscular blockade and 2 minutes after completion of endotracheal intubation ]
  Lowest oxygen saturation between control and intervention groups that did not receive adequate pre-oxygenation only
• Lowest oxygen saturation pre-oxygenation[ Time Frame: Time between neuromuscular blockade and 2 minutes after completion of endotracheal intubation ]
  Lowest oxygen saturation between control and intervention groups that did receive
• Difference in baseline and final oxygen saturation[ Time Frame: Decision to intubate through 2 minutes after completion of endotracheal intubation ]
• Difference in oxygen saturation before and after apneic period[ Time Frame: Initiation of neuromuscular blockade through 2 minutes after completion of endotracheal intubation ]
• Desaturation[ Time Frame: Initiation of neuromuscular blockade through 2 minutes after completion of endotracheal intubation ]
  The proportion of patients who desaturate below 90%
• number of attempts[ Time Frame: From first attempt at intubation through completion of endotracheal intubation procedure, approximately 2 minutes. ]
  number of times laryngoscope is placed into the mouth in an attempt to pass an endotracheal tube
• Need for second operator[ Time Frame: From first attempt at intubation through completion of endotracheal intubation procedure, approximately 2 minutes. ]
  A second physician had to attempt intubation
• Need for additional intubating equipment[ Time Frame: From first attempt at intubation through completion of endotracheal intubation procedure, approximately 2 minutes. ]
  The operator needed to change or add equipment to facilitate intubation
• Esophageal intubations[ Time Frame: From first attempt at intubation through entire ED stay, approximately 6 hours. ]
  The proportion of intubations that resulted in the endotracheal tube being placed in the esophagus
• Procedural hypotension[ Time Frame: Initiation of neuromuscular blockade to 2 minutes after completion of endotracheal intubation ]
  Proportion of became hypotensive at any point during the intubation procedure
• Aspiration[ Time Frame: Within 24 hours after intubation procedure was complete ]
  Proportion of patients that had evidence of aspiration
• Hospital length of stay[ Time Frame: Up to 28 days after intubation ]
  Number of days patient is hospitalized
• Number of days intubated[ Time Frame: Up to 28 days after intubation ]
• In-hospital mortality[ Time Frame: Up to 28 days after intubation ]

This RCT is testing the efficacy of apneic oxygenation during endotracheal intubation in the emergency department. Currently the standard practice in the ED when performing endotracheal intubation is that some providers use apneic oxygenation (the application of a nasal cannula at 15LPM) throughout the intubation procedure, while others do not apply apneic oxygenation. Initial literature in the operating room showed that apneic oxygenation helps prevent desaturation during the procedure. However, the latest literature conducted in critical care settings (one study in the ICU and one in the ED) questions the efficacy of this intervention in critically ill patients; however, no harm has been shown. Our study aims to test this intervention further by adding in a special subset of patients that was excluded from prior studies, precipitous intubations, or those patients that have to be intubated quickly and cannot have adequate pre-oxygenation. We hypothesize that apneic oxygenation will be more efficacious in this subset than in the overall ED population. We will randomize patients requiring endotracheal intubation into intervention (apneic oxygenation) and control (no apneic oxygenation). We will measure the lowest arterial oxygen saturation from the start of the intubation procedure through 2 minutes after intubation is complete.

• Other: Apneic oxygenation during endotracheal intubation
  Providing oxygenation through nasal cannula during the apneic phase of endotracheal intubation.

• Experimental: Apneic Oxygenation
  Participants receiving apneic oxygenation
• No Intervention: No Apneic Oxygenation
  Participants not receiving apneic oxygenation