After every failed attempt, change a meaningful variable and escalate early.
Critical actions
After each failed attempt - change one variable
The next attempt should be mechanically different and should not delay oxygenation.
Choose based on the situation
No view: suction, reposition, external laryngeal manipulation, more experienced operator, or change from standard geometry to hyperangulated/low-profile video blade.
Good view but tube will not pass: matched rigid stylet, bougie, smaller ETT, withdraw-and-rotate, or alter blade/tube curvature.
Contaminated airway: large-bore suction and SALAD-style continuous suction.
Video system problem: switch to a functional video device or direct laryngoscope with a prepared adjunct.
Oxygenation deteriorating: stop laryngoscopy and move to BVM/SGA rescue.
Plan to say: Failure was ___. Next device change is ___. Stop threshold is ___.
Optional cognitive support. Choose the option that fits the patient, local equipment, team skill, and protocol.
Pearls
A second attempt should not be a replay of the first. Make the next attempt meaningfully different and keep oxygenation as the priority.
Say aloud: The attempt failed. The current failure mode is __. For the next move we are changing __. Help is coming. Rescue oxygenation is __. If we cannot intubate and cannot oxygenate, we move to surgical airway.
Pitfalls
Repeating the same device, operator, position, and technique
Failure to call for help early
Continuing attempts while oxygenation deteriorates
Delaying supraglottic rescue or front-of-neck access in CICO
Using DART language without defining the local equivalent
Optional just-in-time support
Checklist guidance
About this resource
Created by: Andrew Pirotte, MD; Kyle Brown, MD; Reba Hodge, MD; Amanda Vanderwerf, PharmD, BCEMP; Morgan Kimball, PharmD, BCEMP; Joshua MohessClinical review: Emergency medicine faculty review completed. Medication content reviewed by Amanda Vanderwerf, PharmD, BCEMP, and Morgan Kimball, PharmD, BCEMP.Last reviewed: 2026-07-23Next scheduled review: 2027-01-23Designed for: EM residents, emergency physicians, EMS clinicians, airway educators, and simulation facultyImportant: Educational resource and cognitive-aid guide only; not a bedside order set or substitute for local protocol, medical direction, or clinical judgment.Website contact:[email protected]
Training video
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