There are theoretical reasons why endotracheal intubation can make trauma patients worse. Induction agents can cause hypotension. Positive pressure ventilation decreases venous return and can decrease cardiac output. This is not to mention the potential complications of the procedure itself.
all of this must be balanced with the possible need for a definitive
airway and to ensure oxygenation & ventilation.
trauma patients requiring surgery, is it better to intubate in the ED or wait to go to the
looked at the National Trauma Data Bank (registry data… beware)
and identified 9,667 patients at 253 trauma centers who underwent
hemorrhage control surgery within 60 minutes of ED arrival. To attempt to
minimize confounding, they excluded patients with GCS <8, dead on
arrival, ED thoracotomy, or those “with clinical indications for intubation.”
outcome was mortality when comparing ED intubation vs. in theatre.
mortality for those intubated in the ED was 17% vs. 7% in theatre.
Absolute increase of 10% or a number needed to kill (NNK) of 10.
in the ED is lethal!?
the sicker patients are more likely to get intubated in the ED!
was no exception. ED patients had markedly higher injury severity scales. They
had lower GCS, more chest, lung, heart, thoracic vascular and liver injury. They
were more tachycardic and twice as likely to get a thoracotomy for hemorrhage
tried the usual fancy statistical adjustments that we often see with
observational study design, but this is far from a perfect science.
Studies like this invariably have some residual confounding which makes the interpretation
To be fair,
the authors do a good job of mentioning the study limitations but unfortunately
overstate their conclusion.
is an association between ED intubation and worse outcomes. Yes, but
is this a causal relationship? That is the big question which can only be
answered with a randomized clinical trial.
Seamon MJ, Subramanian M, et al. Emergency department versus operating room
intubation of patients undergoing immediate hemorrhage control surgery. J
Trauma Acute Care Surg. 2023;95:69-77. [link to article]