Background. Prehospital use of video laryngoscopes (VLs) remains rare. We analyzed the type, frequency, and overall success rates for alternative airway devices used when VL failed during a prospective prehospital research study. Methods. This was a post hoc analysis from a multisite, prospective, nonrandomized, crossover trial comparing the placement success rates of two VLs (Storz CMAC, Karl Storz; King VISION [KV], King Systems). Following failed airway management with a VL device, providers were allowed to choose their alternative device (ETI via direct laryngscopy [DL], King, Combitube, or bag–valve–mask). Descriptive analyses were completed for patient, provider, and alternative airway device variables. The frequencies of achieving a good view (Cormack-Lehane score [CLS] ¡Â2) during failed VL attempts were compared between VL devices using a chi-square test. Chi-square was also used to compare the CLS achieved during direct laryngoscopy (DL) with the CLS achieved during failed VL management. Results. Between October 2011 and August 2012, there were 31 failed VL placements in the 94 patients treated. There were no significant demographic differences in patient or provider characteristics. Providers experienced more failures with the KV device than with the CMAC (47.5% vs. 21.1%; p < 0.006). The vast majority of the 31 VL failures were managed with DL (84%). The combined DL success rate was high (88.4%), and did not differ statistically between treatment group (CMAC = 77.7%, KV = 94.1%; p = 0.24). A good view was achieved in 53% of the total VL placement attempts (CMAC = 64%, KV = 45.5%; p = 0.15). When the providers moved to DL, 64% of the total attempts had a good view (CMAC = 46%, KV = 68%, p = 0.20). There was no significant difference in achieving a good view between VL and DL (p = 0.40). Conclusion. Patients who failed VL were most frequently managed by DL, and managed successfully. CMAC offered a better but not statistically better view than KV. When providers moved from CMAC to DL, they reported a worse view, but it did not impact success rate. When providers moved from KV to DL, they reported a better view, raising major concern about the device as a prehospital VL.