Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery

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. 

Of course, all of this must be balanced with the possible need for a definitive airway and to ensure oxygenation & ventilation.

So… for trauma patients requiring surgery, is it better to intubate in the ED or wait to go to the operating theatre?

This study 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.”

The primary outcome was mortality when comparing ED intubation vs. in theatre.

The unadjusted 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.

Intubating in the ED is lethal!?

Wait a minute…

Of course, the sicker patients are more likely to get intubated in the ED!

This study 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 control.  

The authors 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 difficult.

To be fair, the authors do a good job of mentioning the study limitations but unfortunately overstate their conclusion.

There 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.

 

Covering:

Dunton Z, 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]