The trauma airway has quietly become one of the most active battlegrounds in resuscitation science, and 2026 has sharpened the debate rather than settling it. The newest and most directly relevant datapoint is the trauma subgroup analysis of the DEVICE trial, published by Stacy Trent and colleagues in the Journal of Trauma and Acute Care Surgery in August 2026. Of the 1,417 critically ill adults enrolled in the parent DEVICE trial, 338 (24%) were intubated in the setting of traumatic injury; 171 were randomised to a video laryngoscope and 167 to a direct laryngoscope. Successful intubation on the first attempt occurred in 151 of 171 patients (88%) with video laryngoscopy versus 114 of 167 (68%) with direct laryngoscopy - an absolute risk difference of 20 percentage points (95% confidence interval 11% to 29%). Severe complications during intubation and in-hospital outcomes did not differ significantly between the groups. The operators were predominantly emergency-medicine residents and critical-care fellows of relatively limited experience, with a median of 50 prior intubations, and the authors concluded that future guidelines "should encourage VL use as the first-line approach for emergency intubation in trauma, especially for operators with limited experience."
This is a striking effect size - larger than in the parent DEVICE trial, where Matthew Prekker and colleagues reported in the New England Journal of Medicine in 2023 that first-attempt success was 85.1% with video versus 70.8% with direct laryngoscopy (absolute difference 14.3 percentage points, 95% CI 9.9 to 18.7, p<0.001) across a mixed emergency-department and intensive-care population of critically ill adults. The trauma signal is, if anything, stronger, which fits the intuition that the trauma airway is where the difficulties cluster.
Details
To understand why this matters for the exam, it helps to recall what ATLS has traditionally taught and how the 11th edition, launched by the American College of Surgeons in September 2025, has moved. For decades, the ATLS canon treated direct laryngoscopy as the default technique for establishing a definitive airway, with video laryngoscopy positioned - if mentioned at all - as a useful adjunct or rescue device when the direct view failed. The primary survey drilled into every candidate was ABCDE, airway first, and the airway teaching centred on recognising the patient who needed a definitive airway (a cuffed tube in the trachea) and delivering it by rapid sequence intubation, with surgical cricothyroidotomy as the fallback in the "can't intubate, can't oxygenate" scenario.
ATLS 11 has modernised this in two ways that directly intersect with the 2026 evidence. First, and most famously, it revised the mnemonic to xABCDE, formally placing control of exsanguinating external haemorrhage ahead of the airway for the subset of patients bleeding to death - a change the American College of Surgeons described as its most significant. That reordering has been covered elsewhere and is not our focus here. Second, and more quietly, the airway chapter itself changed. Independent peer-reviewed summaries of the new edition - including a review in Injury in 2026 and a companion overview in the Journal of Acute Care and Resuscitation in 2026 - describe ATLS 11 as adopting "context-based airway management techniques," continuing to prioritise rapid sequence intubation after initial resuscitation, but now with video laryngoscopy preferred as a primary intubation tool and with explicit emphasis on volume resuscitation before induction and judicious vasopressor use to blunt peri-intubation hypotension. In other words, the course has caught up with the direction of travel: video first, and a "modified" RSI tailored to the physiology in front of you.
The DEVICE trauma analysis therefore lands as confirmation of a curriculum change already underway, and it is buttressed by a wider literature. A propensity-matched analysis of the National Emergency Airway Registry, covering 4,449 trauma intubations, found first-pass success of 90% with video versus 79% with direct laryngoscopy; after propensity matching, "video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9)" (Trent and colleagues, Annals of Emergency Medicine, 2021). The mechanistic story is coherent: video laryngoscopy improves the glottic view - Cormack–Lehane grade 3 or 4 views were reported in 2% of video cases in the DEVICE trauma cohort - reduces the force and cervical-spine movement required to obtain that view (relevant in the collared trauma patient), and flattens the learning curve for the inexperienced operator who does the majority of real-world trauma intubations.
And yet the evidence-led clinician should resist declaring the direct laryngoscope obsolete, because the opposing case is stronger than the enthusiasm suggests. The most important counter-signal comes from the only large randomised controlled trial to use mortality as its primary trauma endpoint: Dale Yeatts and colleagues, writing in the Journal of Trauma and Acute Care Surgery in 2013, randomised 623 trauma patients at a busy US centre to the GlideScope video laryngoscope or direct laryngoscopy. Overall survival to discharge was no different (video 28 of 303, 9%, versus direct 24 of 320, 8%; p=0.43), video intubation took longer, and - the finding that still haunts the field - a post-hoc subgroup of patients with severe head injury randomised to video laryngoscopy had a higher incidence of desaturation below 80% and higher mortality (reported at around 22% versus 16% with direct laryngoscopy). The proposed explanation is that hyperangulated video devices can lengthen the time to tube delivery, and the severely brain-injured patient tolerates even brief desaturation poorly, converting a technical advantage in "seeing" the cords into a physiological disadvantage in securing them quickly. This is a hypothesis-generating subgroup, not a definitive finding, but it is precisely the kind of nuance an examiner or a thoughtful colleague will probe.
The second steelman for direct laryngoscopy is the soiled airway. The trauma patient with blood, vomit or debris in the pharynx can blind a video camera lens at the very moment it is needed most, whereas the direct line of sight - with suction - can still succeed. This is why every serious airway authority, and ATLS itself, insists that direct laryngoscopy remains an essential skill to retain rather than a museum piece; the pragmatic position emerging from the 2026 data is not "video always" but "video first, with a maintained direct-laryngoscopy competency and a pre-declared failure plan." It is also worth remembering that first-pass success, however appealing, is a surrogate. The DEVICE programme has repeatedly shown that better first-pass success with video does not translate into a demonstrable reduction in the hard outcomes of severe complications or mortality - in the parent trial, severe complications occurred in 21.4% of the video group versus 20.9% of the direct group (absolute difference 0.5 percentage points, 95% CI −3.9 to 4.9). The trauma analysis likewise found no significant difference in complications or in-hospital outcomes. A larger trial powered for these events would be needed to prove the intuitively obvious link between getting the tube first time and preventing peri-intubation cardiac arrest.
If the device debate is maturing, the more provocative 2026 controversy concerns whether the tube should be placed before the patient ever reaches the resuscitation bay. Here the landmark contribution is the causal-modelling study by Amy Nelson and colleagues, published in The Lancet Respiratory Medicine in February 2026. Confronting the reality that a randomised trial of prehospital anaesthesia is ethically and practically almost impossible, the UCL and Severn-based team used data from 6,467 patients at the Southmead Hospital Major Trauma Centre across two cohorts (2012–2017 and 2017–2019). They built a machine-learning model, "Intub-8", using eight routinely collected prehospital measurements to identify patients at high risk, then applied doubly robust causal estimation with inverse-probability weighting to estimate the survival effect of prehospital intubation in that high-risk group. Among patients the model flagged as needing early intubation, prehospital intubation conferred a 10.3% absolute reduction in 30-day mortality; the conditional average treatment effect of prehospital intubation was −0·103 (95% CI −0·119 to −0·087). Patients predicted to need intubation but not intubated in the field survived far less often than those not predicted to need it (66.8%, 95% CI 61.3–71.7, versus 93.6%, 95% CI 92.5–94.6; log-rank p<0.001). Scaled UK-wide, the authors estimated the policy would prevent 170 deaths per year (95% CI 148–191), "an effect comparable to the benefit of major trauma centres in England," at an annual cost-effectiveness value of £101 million (95% CI 93–111), and argued for central funding of prehospital critical-care teams with emergency-anaesthesia capability.
The accompanying editorial by Amber den Hollander and Prabath Nanayakkara in the same journal welcomed the analysis as a landmark application of causal inference while cautioning that it remains observational. The caveats are substantial and examinable: all prehospital intubations in the studied region were performed by highly trained physician–paramedic teams, patients who died before hospital arrival were excluded (probably underestimating the benefit, but also limiting generalisability), and residual confounding cannot be excluded from any non-randomised design, however sophisticated the modelling. The finding sits alongside a genuinely divided older literature - for example a 2026 matched cohort from Navarra, Spain, published in the European Journal of Trauma and Emergency Surgery by Zulet Murillo and colleagues, in which only 11.1% of 1,909 major-trauma patients underwent prehospital intubation and the survival association remained contested. The steelman against field intubation is well rehearsed: it prolongs scene time, risks unrecognised oesophageal or endobronchial placement, and can induce or worsen hypotension and hypoxia in exactly the patients least able to tolerate them - which is why systems staffed by less experienced intubators have historically shown harm, and why the Nelson signal may be inseparable from the expertise of the teams that produced it.
One further 2026 thread deserves a brief mention because it feeds the "modified RSI" language in ATLS 11: the choice of induction agent. The RSI trial comparing ketamine and etomidate, discussed widely across critical-care media in early 2026, randomised 2,365 critically ill adults and found no difference in 28-day mortality (28.1% with ketamine versus 29.1% with etomidate; adjusted absolute difference −0.8 percentage points, 95% CI −4.5 to 2.9, p=0.65) but more cardiovascular collapse with ketamine (22.1% versus 17.0%). Crucially, that trial excluded trauma patients, so it cannot be cited as trauma evidence - but it reinforces the ATLS 11 emphasis on optimising haemodynamics around induction rather than fixating on a single "safe" drug.
What this means for your ATLS exam
The examinable tension here is between the timeless ATLS framework and the modern technique layered on top of it. For a written or viva question asking how you will secure the airway of a trauma patient who cannot maintain or protect it - the classic indications being a Glasgow Coma Scale of 8 or less, apnoea, airway obstruction, or aspiration risk - the safe, mark-winning answer is unchanged in structure: you establish a definitive airway (a cuffed tube in the trachea) by rapid sequence intubation with in-line cervical stabilisation, you have a failure plan, and you proceed to a surgical airway (cricothyroidotomy in the adult) if you cannot intubate and cannot oxygenate. Do not let enthusiasm for new evidence tempt you into skipping the algorithm; ATLS still examines the disciplined sequence, and in the bleeding patient remember that xABCDE now places catastrophic external haemorrhage control first.
Where the modern evidence should surface is in the details that demonstrate you are current. If asked which laryngoscope you would reach for, the correct contemporary answer is video laryngoscopy as the first-line device, particularly given that most emergency intubations are performed by relatively junior operators for whom the first-pass benefit is greatest - cite the direction of ATLS 11 ("context-based" airway management, video preferred) and, if you wish to show reading, the DEVICE trauma data. But score the extra mark by naming the caveats: retain direct laryngoscopy competence for the blood- or vomit-soiled airway that defeats the camera, and be alert to the vulnerable severely head-injured patient in whom any prolongation of intubation and desaturation is dangerous. On prehospital intubation, the safe exam position is that a definitive airway should be secured by the most appropriately skilled provider available and that scene time must be weighed against benefit; you can note that 2026 evidence increasingly supports early intubation of high-risk major-trauma patients when delivered by expert teams, while acknowledging it is not randomised-trial evidence. Finally, if induction agents come up, emphasise haemodynamic optimisation - volume and, where needed, vasopressors before and during induction - rather than dogmatic drug choice.
Recommendations
For candidates and for clinicians updating their practice, the staged approach is as follows. First, in the next few weeks, make video laryngoscopy your default first-look device for trauma intubation while deliberately maintaining direct-laryngoscopy skills - the benchmark that should change this is a soiled airway or device failure, at which point you convert immediately rather than persisting. Second, treat first-pass success as a team performance metric worth auditing locally, but do not assume it guarantees better survival; if your service adopts video-first, track peri-intubation hypoxia and hypotension, especially in head-injured patients, as your safety signal. Third, for those in or advising prehospital systems, the Nelson data justify investment in expert prehospital anaesthesia capability for high-risk patients, but the threshold for extrapolating to your own system should be whether your intubators match the training level of the physician–paramedic teams in that study; if they do not, the historical harm signal should stay front of mind. Finally, for exam preparation specifically, learn the ATLS 11 airway framework as gospel for the structured answer and layer the 2026 evidence on top as the "modern practice" commentary that distinguishes a strong candidate.
References
Trent SA, Schauer SG, Prekker ME, et al. Video versus direct laryngoscopy for tracheal intubation in trauma: A secondary analysis of the DEVICE trial. J Trauma Acute Care Surg. 2026;101(2):359–365. doi:10.1097/TA.0000000000005021. https://pubmed.ncbi.nlm.nih.gov/42112946/
Prekker ME, Driver BE, Trent SA, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med. 2023;389(5):418–429. doi:10.1056/NEJMoa2301601. https://www.nejm.org/doi/full/10.1056/NEJMoa2301601
Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg. 2013;75(2):212–219. doi:10.1097/TA.0b013e318293103d. https://pubmed.ncbi.nlm.nih.gov/23823612/
Nelson AP, Dodds N, Zeina M, et al. Survival effect of prehospital emergency anaesthesia with intubation in risk-stratified patients with major trauma: a causal modelling study. Lancet Respir Med. 2026;14(3):256–266. doi:10.1016/S2213-2600(25)00370-4. https://pubmed.ncbi.nlm.nih.gov/41690329/
den Hollander AG, Nanayakkara PWB. From data to decision: the future of prehospital intubation in major trauma. Lancet Respir Med. 2026;14(3):194–195. doi:10.1016/S2213-2600(26)00002-0. https://pubmed.ncbi.nlm.nih.gov/41690328/
American College of Surgeons. Trauma Care Gets Major Upgrade with Launch of ATLS 11. ACS Brief, 16 September 2025. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/september-16-2025-issue/trauma-care-gets-major-upgrade-with-launch-of-atls-11/
Advanced trauma life support 2025: A brief review of updates. Injury. 2026;57(4):113079. doi:10.1016/j.injury.2026.113079. https://www.sciencedirect.com/science/article/abs/pii/S0020138326000665
Updated Initial Trauma Management: Key Changes in the Advanced Trauma Life Support 11th Edition (2025). J Acute Care Resusc. 2026;3(1):24–27. doi:10.4103/jacresus.jacresus_3_26.
Trent SA, et al. Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry. Ann Emerg Med. 2021. doi:10.1016/j.annemergmed.2021.09.410. https://www.sciencedirect.com/science/article/abs/pii/S019606442100696X
- Zulet Murillo D, Ferraz Torres M, Fortún Moral M, et al. Prehospital endotracheal intubation and 30-day survival in severe trauma: a matched cohort study from Navarra, Spain. Eur J Trauma Emerg Surg. 2026;52(1):194. doi:10.1007/s00068-026-03234-0. https://pubmed.ncbi.nlm.nih.gov/42301409/